Revamped health care reform regulations involving external reviews and coverage decisions ease rules proposed last year.
“Generally, this is good. This eases up—compared to the initial guidance—some requirements that would have been problematic for employers,” said Rich Stover, a principal with Buck Consultants in Secaucus, New Jersey.
One change involves the amount of time health care plan enrollees have to be notified of an urgent-care coverage decision. Last year, regulators said enrollees would have to be notified of an urgent-care decision within 24 hours of receipt of a claim.
But in a joint amendment to the 2010 regulations published in the June 24 Federal Register, the Health and Human Services, Labor and Treasury departments said they will allow plans to make notification-of-coverage decisions within 72 hours, closely following a Labor Department rule.
“This is a welcome change for employers. A 24-hour deadline would have been extremely challenging to meet,” said Sharon Cohen, a lawyer with Towers Watson & Co. in Arlington, Virginia.
“A 24-hour standard—think, for example, of Thanksgiving weekend—would not have been practical,” said Andy Anderson, a partner with Morgan, Lewis & Bockius in Chicago.
Regulators, though, noted that the 72-hour limit is a maximum “and that in cases where a decision must be made more quickly based on the medical exigencies involved, the requirement remains that the decision should be made sooner than 72 hours after the receipt of the claim,” according to the rules published in the June 24 Federal Register.
The latest rules also amend a requirement that notices of available and external claims appeal processes and review be provided in a “culturally and linguistically appropriate manner.”
Under the previous rules, the requirement to provide notices in a language other than English was based on the percentage of plan enrollees who were literate in a common non-English language. For plans that cover more than 100 participants, the threshold was 10 percent of plan participants, or 500 participants, whichever was less.
Under the latest rules, the requirement applies if at least 10 percent of the population residing in a county where an employer’s health care plan enrollees reside are literate in the same non-English language. Currently, 255 U.S. counties meet this standard, including 78 of which are in Puerto Rico, according to the rules.
