HHS Softens PPACA's External Review Requirements

On June 22, 2011, the U.S. Department of Health and Human Services (HHS) and U.S. Department of Labor (DOL) issued a technical release updating the “external review” requirements for health plans and insurers under the Patient Protection and Affordable Care Act (PPACA)¹. These amendments (referred to as the “Technical Amendment”) are still considered an “interim final rule” as the federal government sorts out the details of the new external review processes.

The most recent Technical Amendment alters several key provisions of the external review mandates that were published last summer by the federal government. For background on PPACA’s external review requirements, see the legislative update published by BenefitMall in early March.

Brokers and their clients must stay abreast of their rights to file appeals as the new external review requirements are implemented. This Legislative Alert examines how the Technical Amendment may impact health plans, employers, state regulatory agencies and individual stakeholders. 

External review rights remain a key element of the reforms established by PPACA.  "The right to an external appeal is considered one of the most important consumer protections that you can have," said Steve Larsen, director of HHS’ Center for Consumer Information and Insurance Oversight. "Consumers do not want insurance companies making medical decisions for them or for their families."² PPACA’s external review requirements could apply to as many as 160 million Americans as estimated by some experts³.

The new Technical Amendment alters the original interim regulations that were released in July 2010 by HHS and DOL⁴. The June 2011 Technical Amendment makes several key changes to accommodate the concerns of health plans, employers and others to make the new requirements and regulatory processes more realistic. 

However, many consumer advocates are discontent with these latest revisions. 

The effective date of the new Technical Amendment is July 22, 2011. HHS and DOL also are requesting that interested parties file additional comments by July 25, 2011, regarding a number of issues associated with the external review process⁵.  

BenefitMall will provide additional updates on how the external requirements are being implemented in the states as HHS/DOL complete their evaluation later this summer and disseminate more regulatory guidance on this issue. View a summary of PPACA’s External Review Amendments.

To view past Legislative Alerts, visit the News and Events tab at www.BenefitMall.com, or go to www.HealthcareExchange.com.

The views expressed in this Legislative Alert do not necessarily reflect the official policy, position, or opinions of BenefitMall. This update is provided for informational purposes. Please consult with a licensed accountant or attorney regarding any legal and tax matters discussed herein.

1.    See Technical Release 2011-12 at http://cciio.cms.gov/resources/files/appeals_srg_06222011.pdf and Federal Register. 

2.    http://www.kaiserhealthnews.org/Stories/2011/June/22/External-Appeals-Reg-Jaffe.aspx.

3.    Certain health plans are currently exempted including grandfathered and government health plans. 

4.    See Federal Register, vol. 75, no. 141, pgs. 43330-43364 (July 23, 2010) and U.S. DOL Technical Release 2010-01 (August 23, 2010). See also Federal Register, vol. 75, no. 165, pgs. 52597-52599 (Aug 26, 2010).

See introductory comments at Federal Register.