Changes to PPACA Claims and External Review Rules Include More Transition Relief


On June 24, 2011, the tri-agency task force1 drafting regulations under the Patient Protection and Affordable Care Act (PPACA) published interim final regulations amending the regulations regarding internal claims and appeals and external review processes for group and individual health care coverage issued in July 2010. In addition, the task force issued Technical Releases supplementing the regulations, as well as revised model notices. The PPACA claims and appeals rules do not apply to grandfathered group or individual health plans but do apply to non-grandfathered plans and policies, whether or not subject to ERISA.

The July 2010 regulations provided rules for plan years beginning on or after September 23, 2010. Two subsequent releases delayed the effective date for certain of the rules. Some of the delayed rules become effective for plan years beginning on or after July 1, 2011, while other rules were delayed until plan years beginning on or after January 1, 2012. The 2011 amendments to the regulations and the new releases provide additional transition relief and ease or clarify a number of the rules in the July 2010 regulations. This Legal Alert focuses primarily on changes applicable to group health plans subject to ERISA.

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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.

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