Healthcare Reform Legislation

Healthcare Reform Legislation Finalizes ERISA as Mandatory for All Group Health Plans and All Healthcare Providers Appeals Procedures

The final Health Bill recently passed by the Senate and the House Health bill passed earlier, specify the adoption of Employee Retirement Income Security Act (ERISA) claim regulations in their entirety for all group health plans. The ERISA appeal process will soon be mandatory for all group health plans and healthcare providers as well as consumers.

As explained by Senate Democratic Policy Committee, “The Patient Protection and Affordable Care Act includes health insurance market reforms that will bring immediate benefits to millions of Americans, including those who currently have coverage. The Managers’ Amendment to the bill includes even more early benefits for Americans, and the following benefits will be available in the first year after enactment of the Patient Protection and Affordable Care Act”. A copy of the “Immediate Benefits” is captioned at the end of this newsletter.

In order to benefit from immediate expanded coverage reimbursement, hospitals around the country must master ERISA claims procedures and the appeal process, as all group health plans are mandated to come into complete compliance with six (6) of the enactment, as summarized by the Senate Democratic Policy Committee:

ü Under the Patient Protection and Affordable Care Act, all new health plans will implement, within six months of enactment, an effective process for appeals of coverage determinations and claims. And, states will provide an external appeals process to ensure an independent review.

ERISA appeals procedures were claimed as one of the health insurance reform solutions by the White House Office of Health Reform, as posted in The White House Blog, Where the Road to Health Reform Began, on December 29, 2009 at 11:05 AM EST:

“Health Insurance Reform Solution: Reform will end insurer abuses, lower premiums, and hold insurance companies accountable. … And consumer rights will be enhanced by requiring all insurers to provide effective appeals procedures including outside, independent review of appeals.”

(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and”

(b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.”

ERISA Claim Regulation, the section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000, can be found on the Website of Department of Labor, DOL:

As stated by Robert Gibbs at his White House Press Briefing on December 22, 2009, “health care reform is not a matter of if; health care reform now is a matter of when”. It is widely reported that President Obama is expected to sign the merged Senate and House final bill into law before he delivers the State of the Union address in mid-January 2010.

The provider community, including hospitals and doctors, will need to focus on the portions of the new law that specify how they will be paid.

Claims disputes can be resolved effectively if you know the procedure. Since its initial passage over 35 years ago, the insurance industry has been fully informed of federal ERISA law, while hospitals and other providers have not.

"Entrepreneurs will benefit. Patients and survivors of diseases will benefit. Americans of different backgrounds and ethnicities will benefit," Senate Majority Leader Harry Reid of Nevada said last month.

BEGIN YOUR PREPARATION TODAY BY CALLING CRC, THE ONLY COMPANY FOCUSED EXCLUSIVLY ON ERISA APPEALS FOR HOSPITALS.

Claims Recovery Company (CRC) is an ERISA-specialized claim recovery company in Rockford Illinois. CRC is the only company in the country offering specialized and comprehensive ERISA appeals on behalf of hospitals.

For more information on how to benefit from the new Obama Health Reform and Patient Protection and Affordable Care Act, please contact Mr. Scott Winslow, CEO, CRC at 815-397-8002, or swinslow@crcclaim.com.

“Immediate Benefits” for Hospitals from Senate Democratic Policy Committee:

Immediate Benefits

The Patient Protection and Affordable Care Act includes health insurance market reforms that will bring immediate benefits to millions of Americans, including those who currently have coverage. The Managers’ Amendment to the bill includes even more early benefits for Americans, and the following benefits will be available in the first year after enactment of the Patient Protection and Affordable Care Act.

Access to Affordable Coverage for the Uninsured with Pre-existing Conditions
ü The Patient Protection and Affordable Care Act will provide $5 billion in immediate federal support for a new program to provide affordable coverage to uninsured Americans with pre-existing conditions. This provision is effective 90 days after enactment, and coverage under this program will continue until new Exchanges are operational in 2014.

Access to Quality Care for Vulnerable Populations
ü The Patient Protection and Affordable Care Act makes an immediate and substantial investment in Community Health Centers to provide the funding needed to expand access to health care in communities where it is needed most. This $10 billion investment begins in 2010 and extends for five years.

No Pre-existing Coverage Exclusions for Children
ü The Patient Protection and Affordable Care Act eliminates pre-existing condition exclusions for all Americans beginning in 2014, when the Exchanges are operational. Recognizing the special vulnerability of children, the Managers’ Amendment prohibits health insurers from excluding coverage of pre-existing conditions for children, effective six months after enactment and applying to all new plans.

Re-insurance for Retiree Health Benefit Plans
ü The Patient Protection and Affordable Care Act will create immediate access to re-insurance for employer health plans providing coverage for early retirees, effective 90 days after enactment. This re-insurance will help protect coverage while reducing premiums for employers and retirees.

Closing the Coverage Gap in the Medicare (Part D) Drug Benefit
ü The Patient Protection and Affordable Care Act will reduce the size of the “donut hole,” raising the ceiling on the initial coverage period by $500 in 2010.
ü The Patient Protection and Affordable Care Act will also guarantee 50 percent price discounts on brand-name drugs and biologics purchased by low and middle-income beneficiaries in the coverage gap, beginning July 1, 2010.

Patient Protections
ü The Patient Protection and Affordable Care Act protects patients’ choice of doctors by allowing plan members to pick any participating primary care provider, prohibiting insurers from requiring prior authorization before and woman sees an ob-gyn, and ensuring access to emergency care. This provision takes effect six months after enactment and applies to all new plans.

Extension of Dependent Coverage for Young Adults
ü The Patient Protection and Affordable Care Act will require insurers to permit children to stay on family policies until age 26. This provision takes effect six months after enactment and applies to all new plans.

No Lifetime Limits on Coverage
ü The Patient Protection and Affordable Care Act will prohibit insurers from imposing lifetime limits on benefits. This provision takes effect six months after enactment and applies to all new plans.

Restricted Annual Limits on Coverage
ü The Patient Protection and Affordable Care Act will tightly restrict insurance companies’ use of annual limits to ensure access to needed care, effective six months after enactment for all new health plans. These tight restrictions will be defined by the Secretary of Health and Human Services. When the Exchanges are operational, the use of annual limits will be banned.

Protection from Rescissions of Existing Coverage
ü The Patient Protection and Affordable Care Act will stop insurers from rescinding insurance when claims are filed, except in cases of fraud or intentional misrepresentation of material fact. This provision takes effect six months after enactment and applies to all new plans.

Public Access to Comparable Information on Insurance Options
ü The Patient Protection and Affordable Care Act will enable creation of a new website to provide information on and facilitate informed consumer choice of insurance options.

Health Insurance Consumer Information
ü The Patient Protection and Affordable Care Act will provide assistance to States in establishing offices of health insurance consumer assistance or health insurance ombudsman programs to assist individuals with the filing of complaints and appeals, enrollment in a health plan, and, eventually, to assist consumers with resolving problems with tax credit eligibility. This provision is effective beginning with fiscal year 2010.

Appeals Process
ü Under the Patient Protection and Affordable Care Act, all new health plans will implement, within six months of enactment, an effective process for appeals of coverage determinations and claims. And, states will provide an external appeals process to ensure an independent review.”

To ensure providers receive all the benefits from the new health reform act, Claims Recovery Company will offer free monthly webinars to provide education on how to become compliant with new federal reimbursement laws “within six months of enactment”, as required for all group health plans.