Health reform requires that group health plans and health insurers comply with an external review procedure for appeals of benefit claims. In July 2010, the Department of Labor (DOL), Internal Revenue Service (IRS) and Health and Human Services (HHS) issued Interim Final Rules for group health plans and health insurers regarding external review procedures under the Affordable Care Act. Those regulations contained sixteen minimum standards (see link below).
On March 15, 2013, the Department of Labor issued a Technical Release which granted an extension for insured and self-funded plans (other than federal government plans) struggling to implement the sixteen external review requirements. These plans will be considered in compliance with the external appeals procedures until January 1, 2016 if they comply with the thirteen (13) temporary standards for a state-administered external review procedure (see table below, on the right). Beginning on January 1, 2016, however, self-funded and insured plans’ external review procedures must satisfy the requirements under the July 2010 regulations.
Grandfathered plans are notsubject to the Affordable Care Act’s external review procedures. Click for details of the differences between external appeal schemes.
Some of the major differences between the two external appeal schemes is in the deadlines imposed. For example, the 2010 regulations allow the claimant four months to file a request for external review, while the temporary standard only allows the claimant 60 days to file a request for external review. The 2010 regulations require the IRO to issue its decision within 45 days in a standard external review, while under the temporary standards, the IRO has 60 days to issue its decision. For urgent care claims, the IRO must issue its decision within 72 hours under the 2010 regulations, while the IRO must issue its decision within four business days under the temporary standards.
The temporary standards do not allow a participant to submit additional information for the IRO’s consideration, while the 2010 regulations grant a participant that right. IROs are not assigned through any particular process under the temporary standards and the IROs do not need to be accredited.
To summarize, HHS, the Labor Department and the IRS have accommodated employers and insurers that are experiencing difficulty in establishing fully-compliant external review procedures, by allowing them to implement relaxed procedures until January 1, 2016.