Advertise
Resources
Member, Beacon International Group, Ltd.
WASHINGTON—New federal regulations released Thursday will require health insurers and self-funded employers to speed up the time in which they notify plan enrollees of coverage decisions involving urgent care, among other things.
Under the regulations—mandated by the health care reform law and issued by the Internal Revenue Service and the departments of Labor and Health and Human Services—enrollees would have to be notified of a coverage decision involving urgent care within 24 hours of receipt of a claim.
That is a big change from a 2000 Labor Department rule requiring such decisions to be made within 72 hours of receipt of a claim. The agencies said “electronic communication will enable faster decision-making” compared with a decade ago.
The rules will impose new criteria to avoid conflicts of interest in claims decisions. For example, a health plan could not provide bonuses based on the number of denials made by a claims adjudicator.
In addition, health plans could not contract with medical experts based on their reputation for outcomes in contested cases rather than on their professional qualifications.
The regulations also require that notices of available internal and external claims appeal processes and reviews be provided “in a culturally and linguistically appropriate manner.”
The requirement to provide notices in a non-English language will be based on the number or percentage of plan enrollees who are literate in a common non-English language. For plans that cover more than 100 participants, the threshold is 10% of plan participants, or 500 participants, whichever is less.
The requirements generally would kick in Jan. 1, 2011. However, the new rules would not apply to grandfathered plans. For a plan to retain grandfathered status, an employer, among other things, can't ever raise coinsurance requirements or boost premiums paid by enrollees by more than five percentage points.