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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law

Benefitlawyers.com

 
 

 
 
 
 
 

U.S. Healthcare Crisis Turnaround?

U.S. A.

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The Only Company with Compliant Solutions for All of You


 

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

Photo of President Gerald R. Ford signing Employee Retirement Income Security Act of 1974

President Obama Signing Health Bill on 03/23/2010

President Gerald R. Ford Signing ERISA on 09/02/1974

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans

DOL Seal - Link to DOL Home Page

UNITED STATES

DEPARTMENT OF LABOR

(Links to DOL) ©2010, Jin Zhou, ERISAclaim.com

Patient Protection and Affordable Care Act

Statutory Laws [PDF] [PDF]

 

 

Employee Retirement Income Security Act — ERISA

 

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans

 

ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

 

03/23/2010

Breaking News

 

President Obama Signed Into the Law the Healthcare Legislation to Revamp Healthcare Reimbursement Laws for All Group Health Plans and Health Care Providers

 

The Final Health Reform Bill Has Been Signed By President Obama Into The Law Of The Land For More Than 95% Americans, As The Most Significant Changes Since Medicare Was Created 45 Years Ago. What Does Obama Healthcare Law Mean To Healthcare Providers And Health Plans? The New Federal Reimbursement Laws Protect Health Care Providers with ERISA Internal And External Appeals, Extended Disclosure And Appeal Rights, New Federal UCR Fee Centers And New Federal Simplified, Uniform Standards For Claim Processing And Appeals. The New Federal Reimbursement Laws Will Eventually Eliminate Most Managed care Abuses

 

On March 23, 2010, President Obama signed into law the Senate Bill passed in the House of Representatives, making this year-long debated healthcare legislation into the law of land for more than 95% of Americans, with most significant overhaul to U.S. healthcare delivery system and reimbursement laws. What does this new Obama health law mean to healthcare providers? Lack of Information, Misinformation and Frustrations are faced by all on New Obama Health Reimbursement Laws. Health care providers should be informed of all specific and accurate statutory provisions on all new Obama health law mandates for claim appeals. Although the House amendment Bill to Senate Bill has to be taken up by the Senate and signed into law by President Obama later this week, statutory provisions on appeals and reimbursement laws were not amended by the House, thus the Senate Bill signed by President Obama is final for claims processing and appeals.

 

According to Dr. Jin Zhou, president of ERISAclaim.com, a national ERISA expert, and reimbursement compliance consultant, contrary to popular misinformation, the Obama health law, Patient Protection and Affordable Care Act, has established significant consumer protections and plan claim processing and appeal simplification to reduce administrative costs and enhance provider reimbursement rights and patient protections. New Obama health law incorporates or adopts existing ERISA claim regulation in its entirety as internal ERISA appeal mandates, and Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners as external ERISA appeal mandates as final and binding authority to all parties, in absence of judicial appeals. New Obama health law upgraded and extended existing ERISA appeal regulation with new EOB requirements, greater patient and provider rights to access to entire claim file and to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process. New Obama health law also established federal UCR (Usual, Customary and Reasonable) fee center to track and publish UCR fee schedules to the public, to end most commonly disputed reimbursement nightmares for all parties. Every group health plan and health care providers have six months after enactment of the act to come into complete compliance with new Obama health reimbursement laws. To ensure every patient and provider appeal rights, new Obama health law provides consumer assistance on mandatory ERISA internal and external appeals. More compliance and mandate information will be discussed at the webinar.

 

“After the legislation becomes the law of land for America health care, it is time for everyone who truly cares about reimbursement and compliance to forget about yesterday's legislation enthusiasm, set aside personal emotions and political preferences, to get hands on today’s new reality, statutory and regulatory compliance and reimbursement by learning and mastering new rule of the game for health care reimbursement through compliance”, said Dr. Jin Zhou, president of ERISAclaim.com.

 

Dr. Zhou also explains that ERISA has been the only governing federal law for claims denials and appeals procedures for about 176 million Americans covered under employment-based health plans for the past 35 years.

Although the new Obama health law will not convert non-ERISA plans to statutorily defined ERISA plans, this new health law will adopt existing ERISA claim regulation and state external review model act from NAIC for additional 32 million Americans.

 

ERISA Appeals Are No Longer A Choice, But Mandates And Compliance For All.

 

Sec. 2719, (a)(2)(A) of Patient Protection and Affordable Care Act provides the following:

 

“`SEC. 2719. APPEALS PROCESS.

 

`(a) Internal Claims Appeals-

 

`(1) IN GENERAL- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—

 

`(A) have in effect an internal claims appeal process;

 

`(B) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes; and

 

`(C) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.

 

`(2) ESTABLISHED PROCESSES- To comply with paragraph (1)—

 

`(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) a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on the date of enactment of this section), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.

 

`(b) External Review- A group health plan and a health insurance issuer offering group or individual health insurance coverage—

 

`(1) shall comply with the applicable State external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; or

 

`(2) shall implement an effective external review process that meets minimum standards established by the Secretary through guidance and that is similar to the process described under paragraph (1)—

 

`(A) if the applicable State has not established an external review process that meets the requirements of paragraph (1); or

 

`(B) if the plan is a self-insured plan that is not subject to State insurance regulation (including a State law that establishes an external review process described in paragraph (1)).

`(c) Secretary Authority- The Secretary may deem the external review process of a group health plan or health insurance issuer, in operation as of the date of enactment of this section, to be in compliance with the applicable process established under subsection (b), as determined appropriate by the Secretary.”

 

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:

 

< http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>

 

New Obama Health Law Eliminate Your UCR Nightmares By Establishing Federal UCR Centers

 

Sec. 2719A of  Patient Protection and Affordable Care Act provides the following:

“SEC. 2719A. PATIENT PROTECTIONS.

 

`(d) Medical Reimbursement Data Centers-

 

`(1) FUNCTIONS- A center established under subsection (c)(1)(C) shall—

 

`(A) develop fee schedules and other database tools that fairly and accurately reflect market rates for medical services and the geographic differences in those rates;

 

`(B) use the best available statistical methods and data processing technology to develop such fee schedules and other database tools;

 

`(C) regularly update such fee schedules and other database tools to reflect changes in charges for medical services;

 

`(D) make health care cost information readily available to the public through an Internet website that allows consumers to understand the amounts that health care providers in their area charge for particular medical services; and

 

`(E) regularly publish information concerning the statistical methodologies used by the center to analyze health charge data and make such data available to researchers and policy makers.

 

`(2) CONFLICTS OF INTEREST- A center established under subsection (c)(1)(C) shall adopt by-laws that ensures that the center (and all members of the governing board of the center) is independent and free from all conflicts of interest. Such by-laws shall ensure that the center is not controlled or influenced by, and does not have any corporate relation to, any individual or entity that may make or receive payments for health care services based on the center's analysis of health care costs.”

 

<http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3590.eas:>

 

More Exclusive Legal Documents on Patient Protection And Affordable Care Act Are Available On Senate Democratic Policy Committee < http://dpc.senate.gov/dpcdoc-sen_health_care_bill.cfm>

 

Immediate Benefits:

 

Immediate Benefits < http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

 

Implementation Timeline < http://dpc.senate.gov/healthreformbill/healthbill50.pdf>

 

More Legal Documents on House Amendment Are Available From Committee of Rules Of The U.S. House Of Representatives

 <http://www.rules.house.gov/bills_details.aspx?NewsID=4606>

 

Text of the Amendment to the Amendment in the Nature of a Substitute

< http://docs.house.gov/rules/hr4872/111_managers_hr4872.pdf>

 

Summary of the Amendment to the Amendment in the Nature of a Substitute

< http://www.rules.house.gov/amendment_details.aspx?NewsID=4611>

 

Text of the Amendment in the Nature of a Substitute

< http://docs.house.gov/rules/hr4872/111_hr4872_amndsub.pdf>

 

Section-by-Section of the Amendment in the Nature of a Substitute

< http://www.rules.house.gov/111_hr4872_secbysec.html>

 

Text of the Senate Amendments to H.R. 3590 (Senate health bill)

< http://docs.house.gov/rules/hr4872/111_hr3590_engrossed.pdf>

 

President Obama Wanted You To Do New ERISA Appeals If You Feel You Were Unfairly Denied A Claim

 

            For healthcare providers and patients, President Barack Obama explained this new ERISA Appeals on Jan 09, 2010:

 

“WASHINGTON – In his weekly address, President Barack Obama discussed the benefits of health reform that Americans will receive in the first year, and how reform will help build a new foundation for American families.  After reform becomes law, uninsured Americans with a pre-existing condition will be able to purchase affordable coverage, insurance companies will be prohibited from imposing lifetime and annual limits on care, small business will receive tax credits to purchase coverage for their employees, along with many other changes.  In short, patients and doctors will have more control over health care decisions, and insurance company bureaucrats will have less.”

 

And there will be a new, independent appeals process for anyone who feels they were unfairly denied a claim by their insurance company."

 

Weekly Address: President Obama Outlines Benefits of Health Reform to Take Effect This Year <http://www.whitehouse.gov/the-press-office/weekly-address-president-obama-outlines-benefits-health-reform-take-effect-year>

 

The Official Interpretation on Time line for ERISA Internal and External Appeals from Senate Democratic Policy Committee:

 

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.”

< http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

 

Free New Obama Health Law Webinars, as a continuation of ERISAclaim.com monthly webinar for past two months on the subject, will now be offered on daily basis for several weeks, weekly basis for two months and monthly basis for the rest of 2010 in the wake of the President Obama signing into law the most significant healthcare reform in America and urgent and tremendous amount of demand from healthcare providers and health plans. The time for each free webinar is 60 minutes, from 11 AM to 12 PM central standard time. Registration is free for all. The Webinar Handout is also available and free to download at: http://www.erisaclaim.com/Free_ERISA_Webnars.htm.

 

The New Obama Healthcare Reimbursement Law weekly and monthly Webinars, ERISA Claim Specialist Certification Programs and ERISA Appeal Department Programs were also available from ERISAclaim.com because ERISA Internal and External Appeals are now mandatory for all group health plans and healthcare providers under new Obama Healthcare Reform Laws.

 

In the past 10 years, ERISAclaim.com has been the only ERISA Specialized Company offering the most practical and comprehensive ERISA education, consulting and publishing services for healthcare providers in administrative ERISA appeals for real problem oriented denials under the most mysterious 35-year-old federal law, ERISA. Dr. Jin Zhou, president ERISAclaim.com has been regarded as the Godfather of ERISA claims for healthcare providers by some in Professional billing and coding industry.

 

For more information or to arrange an interview, please contact Dr. Jin Zhou, president of ERISAclaim.com at 630-808-723 and ERISAclaim@aol.com or visit: <http://www.erisaclaim.com/Free_ERISA_Webnars.htm>

 

###

 

 

Healthcare Reform News Letter

 

 

01/05/2010

 

The New Healthcare Reform Is Final on Provider Reimbursement Laws:

ERISA Appeals Procedures Mandatory for All Group Health Plans and Healthcare Providers

 

The Final Health Bill Passed In Senate On Christmas Eve Is Completely Consistent With House Health Bill By Incorporating ERISA Claim Regulation In Its Entirety For All Group Health Plans Into Obama Health Reform, For 200 Million Americans Under New Obama Universal Healthcare Laws. ERISA Appeal Process Is Now Mandatory For All Group Health Plans And Healthcare Providers As Well As Consumers. First Free Monthly ERISA Webinar starts on 01/18/2010, and First Advanced ERISA Claim Specialist Certification Program Starts in Feb. 2010.

 

Hanover Park, IL, Jan. 05, 2010 – The final Managers' Amendment of Senate Health Bill, HR3590, Patient Protection and Affordable Care Act added a special section, Sec. 2719, (a)(2)(A), to incorporate ERISA claim regulation, 29 CFR §2560.503.1 in its entirety for all group health plans and all health insurance Companies offering group health coverage. The final Senate Bill is completely consistent with House Bill, HR3962, Affordable Health Care for America Act, which has the exact same ERISA provision in the Sec. 232, Requiring Fair Grievance And Appeals Mechanisms. Therefore, the new health care reimbursement laws from Obama Healthcare Reform are completely a done deal from legislation in the making as a matter of “what”, for all payers and providers. ERISA will be the only governing federal law for claims denials and appeals procedures for group health plans after January of 2010 for an additional 30 million Americans who are otherwise uninsured today. ERISA has been the only governing federal law for claims denials and appeals procedures for about 170 million Americans covered under employment-based health plans for the past 35 years. The new ERISA appeal provision will be effective immediately upon the enactment of the Health Bill, and all group health plans will have 6 months after the enactment of the Act to come into complete compliance with appeals provisions of the new Obama federal healthcare laws.

 

ERISA Claims Procedures Are Mandatory For All Group Health Plans and All Healthcare Providers

 

The final Senate Health Bill, HR3590, Patient Protection and Affordable Care Act added a special section, Sec. 2719, (a)(2)(A), which provides the following:

 

‘‘(2) ESTABLISHED PROCESSES.—To comply with paragraph (1)—

 

(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”

 

< http://democrats.senate.gov/reform/managers-amendment.pdf>

 

The Sec. 232 (b) of House Bill, HR3962, Affordable Health Care for America Act, provides the following:

 

“Section 232, Requiring Fair Grievance And Appeals Mechanisms.

 

(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.”

 

< http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3962.pcs:>

 

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:

 

< http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>

 

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 the law before he delivers the State of the Union address in mid-January 2010.

 

“Immediate Benefits” and How to Benefit Within Six Months Of Enactment?

 

As explained by Senate Democratic Policy Committee, the maker of the Senate Health Bill,

 

“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”.

 <http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

 

A copy of the “Immediate Benefits” relevant to providers is captioned at the end of the news letter.

 

In order to benefit from all of these immediate expanded coverage reimbursements, healthcare providers must master ERISA claims procedures and appeal process, as all group health plans are mandated to come into complete compliance within six months of the enactment, as summarized by the Senate Democratic Policy Committee:

 

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.”

 

<http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

 

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.”

 

After the New Year, as soon as Congress begins the task of merging the Senate Bill with the House Bill for Obama’s signature, the Congress and the main stream media will be busy in explaining to the American people how the new Obama Health Reform would affect people who already have health coverage through employment-based plans and also people who are not otherwise insured today, and who will really be responsible for paying for the universal coverage.

 

“But, no one is talking about the real important enforcement issues, as the new solution in Obama Health Reform, for ERISA claims and appeals process as the final step of health care delivery, for about 200 million Americans”, said Dr. Jin Zhou, the president of ERISAclaim.com, the nation’s leading expert in ERISA claims appeals.

 

“We must realize that whether the entire U. S. healthcare delivery system under Obama Health Reform will succeed or fail finally depending upon whether the new universal care can or will be paid for, properly to the healthcare providers by the health plans and insurance companies, or the claims disputes can be resolved effectively under the new Obama Health Reform with ERISA appeals procedures”, as explained by Dr. Jin Zhou of ERISAclaim.com.

 

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

 

Dr. Zhou further stated that “entrepreneurs from health plans and healthcare providers must now comply with and master ERISA claim regulations in order to benefit under the new healthcare legal and market environment, to either get paid or contain the costs legitimately.”   

 

ERISAclaim.com Can Help You Get Paid Through Compliance

 

In order to help healthcare providers to get all the benefits from the new Obama health reform, ERISAclaim.com will offer free monthly Webinars, starting on Jan. 18, 2010, to educate healthcare providers and health plans to come into compliance “within six months of enactment” with new federal reimbursement laws, as required for all group health plans, under the Patient Protection and Affordable Care Act.

 

ERISAclaim.com will also offer basic ERISA Claims and Appeals Seminars and Advanced ERISA Claim Specialist Certification Programs (ECSC), starting in Feb 2010.

 

In the past 10 years in USA, ERISAclaim.com has been the only ERISA Specialized Company offering the most  practical and comprehensive ERISA education, consulting and publishing services for healthcare providers in administrative ERISA appeals for real problem oriented denials under the most mysterious 35-year-old federal law, ERISA.

 

For more information or to arrange an interview, please visit http://www.erisaclaim.com/certification.htm, or contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.

 

###

 

 

 

Official Document on “Immediate Benefits” from Senate Democratic Policy Committee, the Maker of the Senate Health Bill, The Captioned Are Only Relevant to Healthcare Providers:

 

<http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

 

 

 

“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.”

 

 

 
 

 

ERISA & Claim Denials

Aetna Video Shows ERISA Patients Mistreated

 

"According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

 

ERISA & Health Claim
What Is ERISA and How Does It Affect Patient Rights?

 

"ERISA was enacted in 1974 to protect the pension and welfare benefits that employers provide their workers. It currently covers about 2.5 million health plans and 125 million workers, retirees, and dependents."

 

Department of Labor

 
"A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise.

Most private sector health plans are covered by the

 Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law."

 

 

$10,600 ERISA Claim

Recent Federal Court Ruling in a Case with $10,600 medical claim, insurance Co. refused to pay, provider made numerous demand for payment in almost one year, but no appeals filed, the court dismissed the lawsuit because provider failed to exhaust administrative remedy, as required under ERISA, by filing ERISAclaim appeals.  This situation is so popular in health-care community.

 

 

 

 

Agree to terms and conditions

"Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply."

 

CIGNA - Coverage Positions/Criteria
"The terms of a participant's particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. If these Coverage Positions are inconsistent with the terms of the member's specific benefit plan, then the terms of the member's specific benefit plan always control."

 

UnitedHealthcare Medical Policies

"By clicking "I agree," you agree to be bound by the terms and conditions expressed below, in addition to our Site Use Agreement.

UnitedHealthcare medical policies have been made available to you as a general reference resource. When reading these policies you agree that:

Our Medical Policy is not your patient's Benefit Plan.

Your patient's medical benefits are governed and determined by a benefit document, either a Certificate of Coverage or a Summary Plan Description. You should not rely on the information contained in this Web site section to determine your patient's medical benefits.
 

  1. Federal and state mandates and the patient’s benefit document take precedence over these policies.

  2. The patient’s benefit document lists the specific services that have coverage limits or exclusions.


Our Medical Policy does not address every situation and individuals should always consult their physician before making any decisions on medical care."

 

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description

Sec. 1027.

Retention of records
Sec. 1104.
Fiduciary duties

Sec.1106.

Prohibited transactions

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:

Regulations

        Selected links:

2520.102-3 Contents of summary plan description.
2560.503-1 

Claims procedure.

 

 

   
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