Health Plan Administration

[Guidance Overview] More Guidance on PPACA-Mandated Claims Review Procedures
Excerpt:"The Departments of Labor and Health and Human Services also released model forms by which group health plans will be able to provide claimants with notice of adverse benefit determinations consistent with the interim final regulations issued in July 2010."(Deloitte via BenefitsLink.com)

[Guidance Overview] Year-End Roundup for Employee Benefit Plans: What Needs to Be Done Now?
Excerpt:"The [target page] is an overview of the top benefits issues that employers should consider."(Proskauer Rose LLP)

[Guidance Overview] Court Clarifies ERISA Benefits Disputes Discovery Rules
Excerpt:"A federal appellate court has ruled that parties in [ERISA] benefit plan suits have limits on their pre-trial discovery rights about plan administrators with conflicts of interest. The 10th U.S. Circuit Court of Appeals asserted that ERISA litigants are barred from such fact-finding when the issue is a plaintiff's benefits claims, but that plaintiffs can do limited fact-finding when it comes to the actions of plan officials who are both insurer and administrator."(PLANSPONSOR.com)

[Guidance Overview] Year-End Amendment Deadline for Group Health and Cafeteria Plans
Excerpt:"Recent health care reform legislation imposes additional coverage, notice and enrollment requirements on group health plans, including self-insured plans. These new obligations will require changes to open enrollment procedures and most group health and/or cafeteria plans will need to adopt conforming amendments by December 31, 2010."(Buchanan Ingersoll&Rooney PC)

[Guidance Overview] What External Review Requirements Must be Met Under PPACA
Excerpt:"These new requirements apply to both individual and group health plans (insured and self-funded), but do not apply to grandfathered plans."(PLANSPONSOR.com)

[Guidance Overview] Guidance and Model Notices Issued on Reviews of Health Benefit Claims (PDF)
2 pages. Employer actions are suggested. (Milliman)

[Guidance Overview] More Guidance on Claims and Appeals Requirements for 2011
Excerpt:"In general, . . . self-funded plans should know: Self-insured group health plans have been granted an interim enforcement safe harbor until further notice. In order to avoid penalty during the enforcement safe harbor, a self-insured group health plan must either (a) comply with the standard and expedited external review procedures detailed in the guidance (which are based on the new state minimum procedures), or (b) voluntarily comply with a state process (assuming that the state is willing to allow access to its external review process). The agencies intend to issue additional guidance in the future with model language for the plan's SPD, describing the plan's new internal claims and appeals and external review procedures."(Holland&Hart LLP)

Maintaining Grandfathered Status for Health Care Plans Appears to Be Exercise in Frustration, Says Expert
Excerpt:"The list of triggers that negate a health-care plan's'grandfathered'status is long and easy to trip over, including such actions as switching insurance carriers and tinkering with employees'share of healthcare costs in any substantive way."(CFO.com)

[Guidance Overview] Vigilance and Policies Needed to Meet New Preventative Health Care Cost-Sharing Requirements
Excerpt:"When reviewing the potential impact of these regulations and their internal operating procedures, providers should consider: documenting and implementing internal policies and procedures with respect to the billing treatment of preventive services and office visits; maintaining communication with health plans and insurance providers, as many have begun implementing the new preventive care regulations; educating patients about potential and actual changes in the collection of cost-sharing amounts and about the provider's billing practices with respect to preventive services and office visits."(Pepper Hamilton LLP)

[Guidance Overview] Federal External Review of Benefit Claims and Appeals under Health Care Reform
Excerpt:"This'WorkCite'deals specifically with a new federal process for the external review of benefit claims and appeals under self-insured group health plans that are not'grandfathered'plans under the Act."(McGuireWoods LLP)

[Guidance Overview] Additional Guidance for Plan Sponsors on Health Benefits Appeals and External Review Processes (PDF)
4 pages. (Buck Consultants)

Time to Prepare for 2011: Issues You May Need to Address Before the End of 2010 (PDF)
3 pages. (Holland&Hart LLP)

[Guidance Overview] Hodgson Russ LLP - Employee Benefits Developments August 2010
Nice summaries of important recent ERISA cases. (Hodgson Russ)

Striking Coca-Cola Workers Sue After Healthcare Benefits Terminated
Excerpt:"'On or about August 24, 2010, Coca-Cola unilaterally and without notice or lawful authority ceased to permit or enable the class representatives and putative class members to make the employee contributions toward the cost of their coverage under the plan through monthly payroll deduction,'states the suit, which seeks class action status on behalf of approximately 500 full-time Coca-Cola employees."(Business Insurance)

[Guidance Overview] CMS Announces Medicare Part D Premium Amounts for 2011
Excerpt:"The national average Part D premium for Medicare prescription drug coverage will reach $32.34 in 2011, up from $31.94 per month in 2010, CMS estimates."(Mercer)

HHS Pushes Competition With Health Insurance Site
Excerpt:"HealthCare.gov hopes transparency on health policy costs, claim denials drives down costs and helps consumers and businesses make better decisions."(Information Week)

Consumers Won Reversals for 47% of Health Claim Denials in New York
Excerpt:"[The] Consumer Guide to Health Insurers [issued by the New York State Insurance Department] indicates that of the 71,787 cases where people were seeking to reverse a health insurer's denial of coverage, exactly 33,921 won their appeals."(Insurance&Financial Advisor)

Health Insurers, Employers May Battle Lawsuits, Pay Out Big-Ticket Claims Under Healthcare Reform
Excerpt:"Not requiring plan members to use their external review options as a precondition to filing a lawsuit could increase legal costs . . . . Plans must make available external review mechanisms with independent review organizations, but going directly to court is allowed."(Messenger-Inquirer via Thomson Business Intelligence Service on InsuranceNewsNet.com)

Most Large Employers Will Change Health Plan Designs in Spite Of, Or Because Of, Health Reform
Excerpt:"More than half (53%) of large employers plan to proceed with health plan design changes for 2011, in spite of the threat of losing grandfathered plan status under health reform, according to a survey from the National Business Group on Health (NBGH)."(Wolters Kluwer Law&Business)

[Guidance Overview] Guidance Provided on Federal External Review Procedures for Self-Insured Plans; Model Notices Issued
Excerpt:"Though this latest guidance provides self-insured plans a fuller picture of what satisfying the external review rules will entail, the resulting compliance burden is daunting, given how soon these changes go into effect."(Employee Benefits Institute of America)

[Official Guidance] Text of Proposed DOL Regs Restating and Amending Procedures for Prohibited Transaction Exemptions (PDF)
22 pages. Excerpt:"[T]he Department would require the disclosure of the following information from a qualified independent fiduciary: A copy of such fiduciary's engagement letter with the plan describing the duties the fiduciary will undertake on behalf of the plan; a detailed explanation of why the proposed transaction is in the interests of the participants and beneficiaries; a statement that, in instances where the transaction is ongoing, the fiduciary agrees to monitor the proposed transaction throughout its duration on behalf of the plan, taking any appropriate action to safeguard the interests of the plan; what qualifications the fiduciary has to perform these duties on behalf of the plan and the level of ERISA experience the person has; and a representation to the effect that such fiduciary understands and acknowledges his or her ERISA duties and responsibilities in acting as a fiduciary on behalf of the plan. . . . As a general matter, an independent fiduciary retained in connection with an exemption transaction must receive no more than a de minimis amount of compensation from the parties in interest to the transaction or their affiliates."(Employee Benefits Security Administration, U.S. Department of Labor)

[Opinion] Hewitt Comments on Interim Final Rules Related to Lifetime and Annual Limits, Rescissions
Excerpt:"Hewitt's comment letter . . . addresses several issues as they relate to employer-sponsored health plans, including: Lifetime and Annual Limits; Definition of Essential Health Benefits; Rescissions; Mini-Med Waiver Program[.]"(Hewitt Associates)

[Guidance Overview] Internal Claims and Appeals and External Review Process under Health Care Reform (PDF)
4 pages. (Reinhart Boerner Van Deuren s.c.)

[Guidance Overview] Model Notices for PPACA's Claims and Appeals Regulation and Interim Guidance on the Federal External Review Process (PDF)
6 pages. Excerpt:"On August 23, 2010, [DOL, HHS, and Treasury] jointly released model notices that non-grandfathered plans and health insurance issuers may use to satisfy new requirements under [PPACA] regarding adverse benefit determinations and appeals of adverse benefit determinations."(Groom Law Group)

[Official Guidance] Federal Agencies Announce Availability of Model Forms for Health Plan Claims, Appeals and External Review; Interim Enforcement Rule Prescribed (PDF)
3 pages. Excerpt:"[New] EBSA Technical Release No. 2010-01 . . . provides an interim enforcement safe harbor for non-grandfathered self-insured group health plans not subject to a State external review process, and therefore subject to the Federal external review process. (In the case of health insurance coverage offered in connection with a group health plan, the issuer has primary responsibility to comply with the interim final regulations.) This interim enforcement safe harbor applies for plan years beginning on or after September 23, 2010 and until superseded by future guidance . . . ."(U.S. Department of Health&Human Services; U.S. Department of Labor; U.S. Department of the Treasury)

Health Reform Presents Big Opportunity for Benefits Outsourcing
Excerpt:"The International Data Corporation (IDC) forecasts that U.S. employee benefits outsourcing services spending in 2010 will grow 3.8% over 2009."(PLANSPONSOR.com)

[Guidance Overview] Interim Procedures for Federal External Review and Model Notices under Health Reform (PDF)
4 pages. Excerpt:"Grandfathered health plans are not subject to any of the claims and appeals changes under PPACA, including the external review. However, if a group health plan or benefit package/option that is part of a group health plan loses its grandfathered health plan status, it must comply with these new claims and appeals requirements."(Hewitt Associates)

Employers Urge Regulators to Ease Rules for Keeping Health Plan'Grandfathered'Status Under Reform
Excerpt:"Extensive comments from employer groups urge more flexible rules giving employers greater ability to control costs and make other plan changes without losing grandfathered status. Specific recommendations include easing cost-sharing and contribution restrictions and allowing plans to switch from insured to self-insured status and to make network provider or formulary changes."(Mercer LLC)

[Official Guidance] Text of Technical Release on Interim Procedures for Federal External Review Relating to Internal Claims and Appeals and External Review Under PPACA (PDF)
8 pages. (U.S. Employee Benefits Security Administration)

[Official Guidance] Text of Model Notice of Adverse Benefit Determination
2 pages. (U.S. Employee Benefits Security Administration)

[Official Guidance] Text of Model Notice of Final Internal Adverse Benefit Determination
2 pages. (U.S. Employee Benefits Security Administration)

[Official Guidance] Text of Model Notice of Final External Review Decision
2 pages. (U.S. Employee Benefits Security Administration)

[Guidance Overview] New Internal and External Review Requirements for Claims and Appeals Procedures under Reform
Excerpt:"Effectively, these new requirements mean that group health plans must review appeals immediately upon receipt to allow for potential interim'mini appeals'prior to the deadline for responding to the appeal. In addition, plans that currently allow for two levels of appeal might consider reducing that to one to maximize the time allowed for the above process to take place."(Jones Day)

[Guidance Overview] Guidance on Claims and Appeals Procedures for Group Health Plans Under Health Reform
Excerpt:"Under the regulations, group health plans must provide notices of an adverse benefit determination and of available internal claims and appeals procedures and external review processes in a culturally and linguistically appropriate manner, including in a non-English language if 25 percent of all participants are literate in the same non-English language (for plans with 100 or more participants, if the lesser of 500 participants or 10 percent of all participants are literate in the same non-English language)."(Davis Wright Tremaine LLP)

Federal Agencies Offer Safe Harbor on External Review Processes under PPACA
Excerpt:"Federal agencies have announced the availability of EBSA Technical Release No. 2010-01, which provides an interim enforcement safe harbor for non-grandfathered self-insured group health plans not subject to a State external review process, and therefore subject to the Federal external review process."(PLANSPONSOR.com)

[Guidance Overview] Failure to Substantially Comply with Claims Procedures Proves Costly to Health Plan
Excerpt:"The plan fiduciary's failure to follow the claims regulations had a surprisingly harsh effect on the outcome in this recent claim for benefits case. Neither the standard of review nor the contractual limitations period served to deflect an award of benefits, attorneys'fees and costs in favor of the claimant."(Roy Harmon via Health Plan Law)

[Official Guidance] Text of Request by Agency for Healthcare Research and Quality for Suggestions on Measuring Health Plan Members'Health Literacy Needs (PDF)
2 pages. Excerpt:"The [AHRQ] is soliciting the submission of instruments or items that measure how well health plans and health providers address health plan enrollees'health literacy needs and how well they communicate with health plan enrollees. . . . The intent of the planned survey is to gain patients'perspective on how well health and health plan information is communicated to them by healthcare professionals and health plans."(Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services)

[Guidance Overview] Regulations Regarding Internal Claims and Appeals and External Review Processes
Excerpt:"The new claims and appeals requirements under health care reform will impose more time-consuming and expensive rules on plan administrators. Plan sponsors considering the benefits of retaining grandfathered status will want to carefully consider these costs. These additional costs may encourage employers to retain grandfathered status. However, in many cases, if an employer has multiple benefit options, only some of which may be grandfathered, it may make more sense to apply all of the new claims procedures to all applicable group health plans in order to make the process consistent for everyone."(Sherman&Howard)

[Opinion] National Association of Insurance Commissioners Defers the Worst Insurance Industry Demands for Weakening the Implementation of Health Care Reform
Excerpt:"'Today the NAIC took a step toward ending the health insurance companies'stranglehold on our health care. The top state insurance regulators from across the nation voted to put patient care above insurance company profits.'"(Consumer Watchdog)

[Guidance Overview] Simple Mailing Mistakes Could Now Be HIPAA Violations Under New HHS Fundraising Rules
Excerpt:"The new regulations propose strengthening the language regarding the opt-out notification, stating that CEs must provide individuals with a'clear and conspicuous'opportunity for the individual to elect not to receive future fundraising communications."(AIS Health.com)

Employee Benefits Update, August 2010 (PDF)
The eight-page newsletter presents select compliance deadlines and reminders; retirement plan developments; health and welfare plan developments, and, general developments. (Reinhart Boerner Van Deuren s.c.)

The New Health Care Law and Early Retirees
Excerpt:"I am age 58 and retired. I understand the new reform law helps employers offer health care coverage to their early retirees. What do I need to do to get this coverage?"(AARP Bulletin)

Groups Seek Swift Clarification on Health Care Reform's Adult Child Coverage Mandate
Excerpt:"The American Benefits Council and the HR Policy Association urged regulators to define'adult child'consistent with current tax law, to give employers flexibility to cover additional classes of dependents, such as grandchildren, without adhering to the mandates that apply to adult children. The groups also want plans to be able to charge higher premiums to cover adult children."(Mercer)

Most Health Plans to Lose Grandfathered Status, Survey Says
Excerpt:"Ninety percent of employers expect their health care plans to lose their grandfathered status by 2014 under the health care reform law because of changes they expect to make, according to a survey . . . ."(Workforce Management (free registration required))

Insurer Mounts Offensive And Defensive Strategies on Health Law
Excerpt:"In the increasingly tense wrangling between the insurance industry and state regulators over the definition of what spending can qualify as medical care under the new health law, one of the loudest lobbying voices is a relatively small player: Cigna Corp."(Kaiser Health News)

The Deal Lawyer's Guide to Hidden Employee Benefit Issues (PDF)
5 pages. (Executive Press, Inc. via Dechert LLP)

[Guidance Overview] New Health Care Claims and Appeal Rules Will Include an Excise Tax
Excerpt:"In contrast to current rules, failure to comply with the Section 503 Regulations as modified by the new internal claims and appeals and external review processes requirements may subject a health plan sponsor or health insurance issuer to a $100 per day per violation excise tax imposed under the Internal Revenue Code, in addition to giving the claimant a green light to file suit."(Littler Mendelson P.C.)

[Guidance Overview] The Implications of Losing'Grandfathered Plan'Status
Excerpt:"What many employers may not know . . . is that under new interim final regulations, if a fully insured health plan loses its grandfathered plan status, it will have to comply with the requirements of the tax code's'nondiscrimination'provisions, which prohibit a plan's more favorable treatment of highly compensated individuals. Prior to these regulations, these nondiscrimination requirements only applied to self-insured plans."(Fox Rothschild LLP)

State Health Care Reform Update as of August 12, 2010
Excerpt:"With the passage of federal health care reform, states will have increasing responsibilities in regard to employer-provided health insurance benefits."(Wolters Kluwer)

[Guidance Overview] Internal and External Claims Review Guidance for Non-Grandfathered Health Plans (PDF)
6 pages. (Buck Consultants)

HHS Issues Interim Final Regs on Pre-Existing Condition Insurance Plan Program (PDF)
3 pages. Excerpt:"The regulations . . . require PCIPs to establish procedures to identify and report to HHS instances where health insurance issuers or group health plans are discouraging high-risk individuals from remaining enrolled in their current coverage, in instances where such individuals subsequently are eligible to enroll in the PCIP."(Brucker&Morra)

DOL Helping Make Sense of Health Care Reform
Excerpt:"[Phyllis Borzi talks about how] new regulations will affect employees and employers. Here, in an edited version, are her comments (supplemented with information from her department's website, www.dol.gov/ebsa)."(San Francisco Chronicle)

[Guidance Overview] Milliman's Monthly Benefit News and Developments, August 2010 (PDF)
2 page summary of legislative and regulatory developments during July. (Milliman)

[Guidance Overview] Regulations Issued Under Health Care Reform on Preventive Services and Internal Claims and Appeals, and External Review Procedures (PDF)
Excerpt:"imposing any cost-sharing requirements (e.g., co-pay, co- insurance, or deductible) on certain in-network preventive health services . . . A list of the preventive services currently falling within one of these categories is available at"(Bryan Cave)

[Guidance Overview] New Guidance on Grandfathered Health Plans
Excerpt:"Employers need to review this new guidance carefully to determine: (1) whether it is important for them to maintain grandfathered status; (2) if so, whether any changes they have already made, are currently contemplating, or want to make in the future, may cause their grandfathered health plans to lose that status; (3) whether losing such status will create additional problems and burdens; and (4) accordingly whether such changes are worth making."(Baker&McKenzie)

[Guidance Overview] New Claims and Appeals Procedures Are Unappealing
Excerpt:"On July 23, 2010, new interim final regulations were issued providing some of the details for the claims and appeals procedures that will apply to all non-grandfathered group health plans beginning with the plan year starting on or after September 23, 2010, or a later loss of grandfathered plan status."(Vorys, Sater, Seymour And Pease LLP)

[Guidance Overview]'ObamaCare'And The ABCs Of'Grandfathered'Plans
Excerpt:"The Patient Protection and Affordable Care Act has divided the world of group health plans in two --'new'group health plans adopted after March 23, 2010, that must conform to the requirements of the new law, and'grandfathered'plans, which are largely exempt from the new law's requirements."(Winston&Strawn)

[Guidance Overview] New Internal and External Claims Procedures for Group Health Plans
Excerpt:"The new rule explicitly requires the plan or issuer to provide continued coverage pending the outcome of the appeal. As under the current regulations, advance notice and an opportunity for an advance review must be provided before benefits for an ongoing course of treatment can be reduced or terminated."(Deloitte via BenefitsLink.com)

[Guidance Overview] New Regulations for Preventive Services and Appeals Processes Under Health Reform
Excerpt:"Language Requirements for Notices. A plan or issuer is considered to provide the notices in a culturally and linguistically appropriate manner if: In the case of a plan that covers fewer than 100 participants at the beginning of the year, and 25% or more of the participants are literate only in the same non-English language, the notice is provided in that language. In the case of a plan that covers 100 or more participants at the beginning of the year, and the lesser of 500 participants or 10% or more of the participants are literate only in the same non-English language, the notice is provided in that language."(Troutman Sanders LLP)

Reminder for Employers about Planning for Current Health Care Coverage (PDF)
2 pages. Excerpt:"This Spotlight reminds employers to take a step back from looking ahead in order to focus on what they need to do now to plan for the coming year . . . ."(The Segal Group, Inc.)