Boardman Law Firm

Employee Benefits Update: More Health Care Reform Regulations - Mandated Preventive Care and Claims/Appeals

By Cindy Van Bogaert
July 26, 2010

Here is your latest Employee Benefits Update from Cindy Van Bogaert, Partner and Chair of the Employee Benefits Practice Group at Boardman Law Firm LLP. This Employee Benefits Update provides information about Health Care Reform guidance that affects employer plans.

Regulations continue to be issued providing essential rules for employer group health plans to comply with Health Care Reform (the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act). The new regulations provide details on Health Care Reform mandates on preventive care and limits on cost-sharing for preventive care as well as new regulations on claims and appeals. The Department of Labor website has the regulations: http://www.dol.gov/federalregister/HtmlDisplay.aspx?DocId=24044&AgencyId=8&DocumentType=2 and http://www.dol.gov/federalregister/HtmlDisplay.aspx?DocId=24056&AgencyId=8&DocumentType=2. Both regulations are generally effective for non-grandfathered plans for plan years starting on or after September 23, 2010.

Plans generally must provide the mandated preventive services and cannot impose cost-sharing charges for the services. See http://www.healthcare.gov/center/regulations/prevention/taskforce.html for details on what types of preventive care will be required. The regulations explain when cost-sharing can be imposed if preventive care is handled in the same office visit as non-preventive care services. It also addresses the ability to impose cost-sharing for preventive care by out-of-network providers.

The Health Care Reform claims and appeals regulations change the current ERISA (Employee Retirement Income Security Act) claims and appeals rules. For example, the definition of an "adverse benefit determination" will include rescissions of coverage. Notification of urgent claims generally will be faster (24 hours instead of 72 hours). Medical experts and claims adjudicators must be impartial and cannot be hired based on their history of denying benefit claims. The claims and appeals procedures include new requirements for those not literate in English. The regulations include detailed changes, including external review and transition rules.

What should employers do?

• Employers need to identify which plans and procedures need to be modified.
• Employers need to understand what options and obligations they have under these new regulations and make changes as mandated.

Please contact me if I can be of assistance.

Upcoming seminars:

• "Health Care Reform: Finding Your Way Through the Maze," telephone seminar through HRWebAdvisor on August 12, 2010. For information: http://www.hrwebadvisor.com/schedule.
• "401(k) Plans" Seminar in Madison, WI on September 14, 2010. For information: click here.
• "Tougher HIPAA Privacy and Security Rules: Learn the New Compliance Requirements," telephone seminar through HRWebAdvisor on September 21, 2010. For information: http://www.hrwebadvisor.com/schedule/detail/tougher-hipaa-privacy-and-security-rules.
• "HIPAA Privacy Training" two seminars, one for the basics and one for new developments, both on October 26, 2010. If you work with employer health benefits, you should consider these training seminars to meet your legal obligations. For information: click here.
• "Fundamentals of Employee Benefit Plans," for the American Law Institute-American Bar Association, in Philadelphia, PA on April 6-8, 2011.

This update is not legal advice. Individuals should seek advice based on their particular circumstances from their own counsel.

If you have any questions or need assistance, please contact Cindy Van Bogaert at (608) 283-7543 or Email.

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