Update: The Claims and Appeals Procedures Required by Healthcare Reform Have Been Amended


On June 24, 2011, some of the provisions of the interim final regulations under the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (together, the “Healthcare Reform Act” or the “Act”) regarding claims and appeals procedures of group health plans were amended. Guidance was also issued regarding the required external review processes following plan internal claims and appeals. This Alert focuses on amendments to the claims, appeals, and review procedures that apply to insured and self-funded nongrandfathered group health plans maintained by nongovernmental employers and that require immediate action.

The Healthcare Reform Act provides that many existing group health plans are “grandfathered”; such plans are not subject to the claims and appeals requirements of the Act. Nongrandfathered plans, however, have been subject to the new claims, appeals, and review requirements of the Act effective for plan years beginning on or after September 23, 2010, but with a good-faith compliance grace period until July 1, 2011.1 During the grace period, the Department of Labor, IRS, and Department of Health and Human Services did not undertake any enforcement action against a health plan that was working in good-faith on implementing the additional claims and appeals and external review requirements. In late June 2011, the interim final regulations under the Act governing the claims and appeals procedures for nongrandfathered group health plans were amended, new technical guidance was issued regarding external appeals, and the grace period for implementing portions of the new requirements was extended. The amendments and guidance clarify, alter, and in some ways relax, the Healthcare Reform Act requirements applicable to employer health plans.

Please see full alert below for more information.

LOADING PDF: If there are any problems, click here to download the file.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Morrison & Foerster LLP | Attorney Advertising

Written by:


Morrison & Foerster LLP on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:

Sign up to create your digest using LinkedIn*

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.

Already signed up? Log in here

*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.