Under the Affordable Care Act (ACA), non-grandfathered group health plans and health insurance issuers must establish procedures governing internal claims and appeals and external review of health plan claims. The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (the ?Departments?) published interim final regulations in July 2010, and an amendment in June 2011, addressing these requirements.
The interim final regulations, as amended, require group health plans and insurers to comply with a state's own external review procedures by January 1, 2012, if those procedures incorporate minimum consumer protections included in the Uniform Health Carrier External Review Model Act issued by the National Association of Insurance Commissioners (NAIC). On June 22, 2011, the Departments issued Technical Release 2011-02 (?T.R. 2011-02?), which established a transition period for the interim final regulation?s temporary NAIC-similar process standards that was to end on January 1, 2014.
On March 15, 2013, the Departments issued Technical Release 2013-01, which extends the transition period established by T.R. 2011-02 until January 1, 2016. Until that time, insurers and self-insured nonfederal governmental plans with established NAIC-similar process standards can continue to follow their state?s external claims and appeals standards, even if the state external review procedures do not meet the interim final regulations? requirements in full. Beginning January 1, 2016, state procedures must satisfy the interim final regulations? minimum standards in full. Otherwise, insurers and self-insured nonfederal governmental plans will have to comply with a federally-administered external review process.
The DOL anticipates providing further clarification of the state standards for external review that reflect comments on the July 2010 regulations, as amended, and subsequent guidance.