Availability of Interim Procedures for Federal External Review and Model Notices Relating to Internal Claims and Appeals and External Review Under the Patient Protection and Affordable Care Act; Notice, 52597-52599 [2010-21206]
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Federal Register / Vol. 75, No. 165 / Thursday, August 26, 2010 / Notices
Core concept
Knowledge
Protect ..................................
Act now to protect yourself from potential catastrophe
later.
Action/behavior
Identity theft/fraud/scams ................................................
Dated: August 18, 2010.
Alistair Fitzpayne,
Executive Secretary.
[FR Doc. 2010–21305 Filed 8–25–10; 8:45 am]
BILLING CODE 4810–25–P
DEPARTMENT OF THE TREASURY
Internal Revenue Service
Proposed Collection; Comment
Request for Form 8809
Internal Revenue Service (IRS),
Treasury.
ACTION: Notice and request for
comments.
AGENCY:
The Department of the
Treasury, as part of its continuing effort
to reduce paperwork and respondent
burden, invites the general public and
other Federal agencies to take this
opportunity to comment on proposed
and/or continuing information
collections, as required by the
Paperwork Reduction Act of 1995,
Public Law 104–13 (44 U.S.C.
3506(c)(2)(A)). Currently, the IRS is
soliciting comments concerning Form
8809, Application for Extension of Time
To File Information Returns.
DATES: Written comments should be
received on or before October 25, 2010
to be assured of consideration.
ADDRESSES: Direct all written comments
to Gerald Shields, Internal Revenue
Service, room 6129, 1111 Constitution
Avenue, NW., Washington, DC 20224.
FOR FURTHER INFORMATION CONTACT:
Requests for additional information or
copies of the form and instructions
should be directed to Joel Goldberger at
Internal Revenue Service, room 6129,
1111 Constitution Avenue, NW.,
Washington, DC 20224, or at (202) 927–
9368, or through the Internet at
Joel.P.Goldberger@irs.gov.
SUMMARY:
mstockstill on DSKH9S0YB1PROD with NOTICES
SUPPLEMENTARY INFORMATION:
Title: Application for Extension of
Time To File Information Returns.
OMB Number: 1545–1081.
Form Number: Form 8809.
Abstract: Form 8809 is used to request
an extension of time to file Forms W–
2, W–2G, 1042–S, 1098, 1099, 5498, or
8027. The IRS reviews the information
VerDate Mar<15>2010
20:12 Aug 25, 2010
Jkt 220001
Choose appropriate insurance.
Build up an emergency fund.
Shop around.
Protect your identity.
Avoid fraud and scams.
Review your credit report.
contained on the form to determine
whether an extension should be granted.
Current Actions: There are no changes
being made to the form at this time.
Type of Review: Extension of a
currently approved collection.
Affected Public: Business or other forprofit organizations, individuals, notfor-profit institutions, farms, and
Federal, State, local or tribal
governments.
Estimated Number of Respondents:
50,000.
Estimated Time per Respondents:
Three (3) hours, 15 minutes.
Estimated Total Annual Burden
Hours: 162,500.
The following paragraph applies to all
of the collections of information covered
by this notice:
An agency may not conduct or
sponsor, and a person is not required to
respond to, a collection of information
unless the collection of information
displays a valid OMB control number.
Books or records relating to a collection
of information must be retained as long
as their contents may become material
in the administration of any internal
revenue law. Generally, tax returns and
tax return information are confidential,
as required by 26 U.S.C. 6103.
Request for Comments: Comments
submitted in response to this notice will
be summarized and/or included in the
request for OMB approval. All
comments will become a matter of
public record.
Comments are invited on: (a) Whether
the collection of information is
necessary for the proper performance of
the functions of the agency, including
whether the information shall have
practical utility; (b) the accuracy of the
agency’s estimate of the burden of the
collection of information; (c) ways to
enhance the quality, utility, and clarity
of the information to be collected; (d)
ways to minimize the burden of the
collection of information on
respondents, including through the use
of automated collection techniques or
other forms of information technology;
and (e) estimates of capital or start-up
costs and costs of operation,
maintenance, and purchase of services
to provide information.
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52597
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Approved: August 18, 2010.
Gerald Shields,
IRS Supervisory Tax Analyst.
[FR Doc. 2010–21207 Filed 8–25–10; 8:45 am]
BILLING CODE 4830–01–P
DEPARTMENT OF THE TREASURY
Internal Revenue Service
RIN 1545–BJ63
DEPARTMENT OF LABOR
Employee Benefits Security
Administration
RIN 1210–AB45
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
RIN 0991–AB70
Availability of Interim Procedures for
Federal External Review and Model
Notices Relating to Internal Claims and
Appeals and External Review Under
the Patient Protection and Affordable
Care Act; Notice
Internal Revenue Service,
Department of the Treasury; Employee
Benefits Security Administration,
Department of Labor; Office of
Consumer Information and Insurance
Oversight, Department of Health and
Human Services.
ACTION: Notice.
AGENCY:
This document announces the
availability of guidance detailing
interim procedures for the Federal
external review process and model
notices both for internal claims and
appeals and for external review
processes under the Patient Protection
and Affordable Care Act.
FOR FURTHER INFORMATION CONTACT:
Amy Turner or Beth Baum, Employee
Benefits Security Administration,
Department of Labor, at (202) 693–8335;
Karen Levin, Internal Revenue Service,
Department of the Treasury, at (202)
622–6080; Ellen Kuhn, Office of
Consumer Information and Insurance
Oversight, Department of Health and
Human Services, at (301) 492–4100.
Customer Service Information:
Individuals interested in obtaining
SUMMARY:
E:\FR\FM\26AUN1.SGM
26AUN1
52598
Federal Register / Vol. 75, No. 165 / Thursday, August 26, 2010 / Notices
mstockstill on DSKH9S0YB1PROD with NOTICES
information from the Department of
Labor concerning employment-based
health coverage laws may call the EBSA
Toll-Free Hotline at 1–866–444–EBSA
(3272) or visit the Department of Labor’s
Web site (https://www.dol.gov/ebsa). In
addition, information from HHS on
private health insurance for consumers
can be found on the Centers for
Medicare & Medicaid Services (CMS)
Web site (https://www.cms.hhs.gov/
HealthInsReformforConsume/
01_Overview.asp) and information on
health reform can be found at https://
www.hhs.gov/ociio/ and https://
www.healthcare.gov.
SUPPLEMENTARY INFORMATION:
I. Background
The Patient Protection and Affordable
Care Act (the Affordable Care Act),
Public Law 111–148, was enacted on
March 23, 2010; the Health Care and
Education Reconciliation Act (the
Reconciliation Act), Public Law 111–
152, was enacted on March 30, 2010.
The Affordable Care Act and the
Reconciliation Act reorganize, amend,
and add to the provisions of part A of
title XXVII of the Public Health Service
Act (PHS Act) relating to group health
plans and health insurance issuers in
the group and individual markets. The
Affordable Care Act adds section
715(a)(1) to the Employee Retirement
Income Security Act (ERISA) and
section 9815(a)(1) to the Internal
Revenue Code (the Code) to incorporate
the provisions of part A of title XXVII
of the PHS Act into ERISA and the
Code, and make them applicable to
group health plans, and health
insurance issuers providing health
insurance coverage in connection with
group health plans. The Departments of
Labor, Health and Human Services, and
the Treasury (the Departments) have
been issuing regulations in several
phases to implement the revised PHS
Act sections 2701 through 2719A and
related provisions of the Affordable Care
Act.
Section 2719 of the PHS Act applies
to group health plans and health
insurance coverage that are not
grandfathered health plans within the
meaning of section 1251 of the
Affordable Care Act.1 It sets forth
standards for plans and issuers
regarding both internal claims and
appeals and external review. The
Departments published interim final
regulations implementing PHS Act
section 2719 on July 23, 2010, at 75 FR
1 The Departments published interim final
regulations implementing section 1251 of the
Affordable Care Act on June 17, 2010, at 75 FR
34538.
VerDate Mar<15>2010
20:12 Aug 25, 2010
Jkt 220001
43330 (the interim final regulations). In
general, the interim final regulations
require plans and issuers to comply
with the requirements of 29 CFR
2560.503–1 (the DOL claims procedure
regulation) and impose specified
additional standards for internal claims
and appeals.
Section 2719 of the PHS Act provides
that plans and issuers in States without
an applicable State external review
process shall implement an effective
external review process that meets
minimum standards established by the
Secretary through guidance and that is
similar to a State external review
process described in PHS Act Section
2719(b)(1). The statute and the interim
final regulations also provide a basis for
determining when plans and issuers
must comply with an applicable State
external review process and when they
must comply with the Federal external
review process. Generally, if a State has
an external review process that meets, at
a minimum, the consumer protections
set forth in the interim final regulations,
an issuer (or a plan) subject to the State
process must comply with the State
process. The regulations include a
transition period for plan years (in the
individual market, policy years)
beginning before July 1, 2011, during
which the Department of Health and
Human Services (HHS) will work
individually with States on an ongoing
basis to assist in making any necessary
changes to incorporate additional
consumer protections so that the State
process will continue to apply after the
end of the transition period. For plans
and issuers not subject to an existing
State external review process (including
self-insured plans), a Federal process is
to apply for plan years (in the
individual market, policy years)
beginning on or after September 23,
2010.
The preamble to the interim final
regulations provided that the
Departments would issue additional
guidance on the Federal external review
process. In addition, the preamble stated
that the Departments would issue model
notices that could be used to satisfy the
notice requirements under the interim
final regulations. This notice announces
the availability of and provides links to
guidance on the interim Federal
external review process, as well as links
to the model notices.
II. Interim Federal External Review
Process for Self-Insured Group Health
Plans
This notice announces the availability
of EBSA Technical Release No. 2010–
01, which provides an interim
enforcement safe harbor for non-
PO 00000
Frm 00095
Fmt 4703
Sfmt 4703
grandfathered self-insured group health
plans not subject to a State external
review process, and therefore subject to
the Federal external review process. (In
the case of health insurance coverage
offered in connection with a group
health plan, the issuer has primary
responsibility to comply with the
interim final regulations.) This interim
enforcement safe harbor applies for plan
years beginning on or after September
23, 2010 and until superseded by future
guidance on the Federal external review
process that is being developed and that
will apply after this interim period.
During the period that this interim
enforcement safe harbor is in effect, the
Department of Labor and the Internal
Revenue Service will not take any
enforcement action against a selfinsured group health plan that complies
with either of the following interim
compliance methods (and if a plan
complies with one of the interim
compliance methods of this notice, no
excise tax liability should be reported
on IRS Form 8928 with respect to PHS
Act section 2719(b)):
• Compliance with the procedures
outlined in Technical Release 2010–01.
The Department of Labor and the
Internal Revenue Service will not take
enforcement action against any plan that
complies with the procedures set forth
in Technical Release No. 2010–01.
These procedures are based on the
Uniform Health Carrier External Review
Model Act promulgated by the National
Association of Insurance Commissioners
(NAIC Model Act) in place on July 23,
2010.2 The Technical Release is
available today on the Department of
Labor’s Web site at: https://www.dol.gov/
ebsa.
• Voluntary compliance with State
external review processes. Alternatively,
States may choose to expand access to
their State external review process to
plans that are not subject to the
applicable State laws, such as selfinsured plans, and such plans may
choose to voluntarily comply with the
provisions of that State external review
process. In such circumstances, while
the interim enforcement safe harbor is
in effect, the Department of Labor and
2 Even though these procedures are based on the
NAIC Model Act, they do not include all the
consumer protections of the NAIC Model Act. For
example, the procedures set forth in this notice do
not include the special provisions for claims
relating to experimental or investigational treatment
and do not include a government agency certifying
and assigning independent review organizations.
The NAIC Model Act is available at https://
www.dol.gov/ebsa and https://www.hhs.gov/ociio/.
Future guidance will address the minimum
consumer protections required under the Federal
external review process after the interim
enforcement safe harbor period.
E:\FR\FM\26AUN1.SGM
26AUN1
Federal Register / Vol. 75, No. 165 / Thursday, August 26, 2010 / Notices
the Internal Revenue Service also will
not take enforcement action against a
plan that voluntarily complies with the
provisions of a State external review
process that would not otherwise be
applicable or available.
The Departments will issue guidance
regarding what process will apply under
26 CFR 54.9815–2719T(d), 29 CFR
2590.715–2719(d), and 45 CFR
147.136(d) no later than July 1, 2011 to
replace the interim process.
III. Interim Federal External Review
Process for Issuers
For issuers in the individual market
and the small group and large group
health insurance markets (including
fully-insured group health plans), there
will be an interim enforcement safe
harbor which will apply only for plan
years (in the individual market, policy
years) beginning on or after September
23, 2010 and until superseded by future
guidance on the Federal external review
process that is being developed and that
will apply after this interim period.
During this limited interim enforcement
safe harbor period, HHS will not take
any enforcement action against an issuer
that complies with the interim
compliance method that will be detailed
by HHS on the Office of Consumer
Information and Insurance Oversight
Web site (https://www.hhs.gov/ociio/).
This method will either involve use of
a State external appeals process or a
temporary process established by HHS.
Prior to July 1, 2011, HHS will issue
further guidance as to which State
external review laws have been
determined to satisfy the minimum
standards of the NAIC Model Act as
identified in 45 CFR 147.136(c). The
Departments will issue guidance
regarding what process will apply under
26 CFR 54.9815–2719T(d), 29 CFR
2590.715–2719(d), and 45 CFR
147.136(d) no later than July 1, 2011 to
replace the interim process.
IV. Model Notices
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Model notices that can be used to
satisfy the disclosure requirements of
VerDate Mar<15>2010
20:12 Aug 25, 2010
Jkt 220001
the interim final regulations 3 are being
posted on the Department of Labor’s
Web site at https://www.dol.gov/ebsa and
the Department of HHS/Office of
Consumer Information and Insurance
Oversight Web site at https://
www.hhs.gov/ociio/. These models
include:
(1) A notice of adverse benefit
determination;
(2) A notice of final internal adverse
benefit determination; and
(3) A notice of final external review
decision.
Model language for the description of
the internal claims and appeals and
external review procedures in the
summary plan description provided to
participants and beneficiaries will be
posted on these websites in the future.
Please note that the Departments
accounted for the actual costs of the
external appeal process taking into
account the model notices when the
interim final regulations were issued.
Signed: August 19, 2010.
Sarah Hall Ingram,
Acting Deputy Commissioner for Services and
Enforcement, Internal Revenue Service.
Signed: August 20, 2010.
Michael L. Davis,
Deputy Assistant Secretary, Employee
Benefits Security Administration, Department
of Labor.
Dated: August 20, 2010.
Jay Angoff,
Director, Office of Consumer Information and
Insurance Oversight.
[FR Doc. 2010–21206 Filed 8–23–10; 11:15 am]
BILLING CODE 4830–01–P; 4510–29–P; 4120–01–P
DEPARTMENT OF THE TREASURY
Internal Revenue Service
Members of Senior Executive Service
Performance Review Boards;
Correction
Internal Revenue Service (IRS),
Treasury.
AGENCY:
3 For rules regarding the form and manner of
notice, see 26 CFR 54.9815–2719T(e), 29 CFR
2590.715–2719(e), and 45 CFR 147.136(e).
PO 00000
Frm 00096
Fmt 4703
Sfmt 9990
ACTION:
52599
Correction to notice.
This document contains a
correction to a notice that was
published in the Federal Register on
Wednesday, August 18, 2010 (75 FR
51168) providing the list of names of
those IRS employees who will serve as
members on IRS’ Fiscal Year 2010
Senior Executive Service (SES)
Performance Review Boards.
SUMMARY:
This notice is effective on
September 1, 2010.
DATES:
FOR FURTHER INFORMATION CONTACT:
Sharnetta Walton, 1111 Constitution
Avenue, NW., Room 2403, Washington,
DC 20224, (202) 283–6246.
SUPPLEMENTARY INFORMATION:
Background
The notice that is the subject of this
correction is pursuant to 5 U.S.C.
4314(c)(4) and announces the
appointment of members to the Internal
Revenue Service’s SES Performance
Review Boards.
Need for Correction
As published, the notice for Members
of Senior Executive Service Performance
Review Boards contains an error that
may prove to be misleading and is in
need of clarification.
Correction of Publication
Accordingly, the publication of the
notice for Members of Senior Executive
Service Performance Review Boards,
which was the subject of FR Doc. 2010–
20331, is corrected as follows:
On page 51169, column 1, in the
preamble, under the caption
SUPPLEMENTARY INFORMATION, the
language ‘‘Charles Hunter, Director of
Field Operations (CI)’’ is inserted
between lines 16 and 17 of the column.
LaNita Van Dyke,
Chief, Publications and Regulations Branch,
Legal Processing Division, Associate Chief
Counsel, (Procedure and Administration).
[FR Doc. 2010–21272 Filed 8–25–10; 8:45 am]
BILLING CODE 4830–01–P
E:\FR\FM\26AUN1.SGM
26AUN1
]]>Agencies
[Federal Register Volume 75, Number 165 (Thursday, August 26, 2010)]
[Notices]
[Pages 52597-52599]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-21206]
-----------------------------------------------------------------------
DEPARTMENT OF THE TREASURY
Internal Revenue Service
RIN 1545-BJ63
DEPARTMENT OF LABOR
Employee Benefits Security Administration
RIN 1210-AB45
DEPARTMENT OF HEALTH AND HUMAN SERVICES
RIN 0991-AB70
Availability of Interim Procedures for Federal External Review
and Model Notices Relating to Internal Claims and Appeals and External
Review Under the Patient Protection and Affordable Care Act; Notice
AGENCY: Internal Revenue Service, Department of the Treasury; Employee
Benefits Security Administration, Department of Labor; Office of
Consumer Information and Insurance Oversight, Department of Health and
Human Services.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This document announces the availability of guidance detailing
interim procedures for the Federal external review process and model
notices both for internal claims and appeals and for external review
processes under the Patient Protection and Affordable Care Act.
FOR FURTHER INFORMATION CONTACT: Amy Turner or Beth Baum, Employee
Benefits Security Administration, Department of Labor, at (202) 693-
8335; Karen Levin, Internal Revenue Service, Department of the
Treasury, at (202) 622-6080; Ellen Kuhn, Office of Consumer Information
and Insurance Oversight, Department of Health and Human Services, at
(301) 492-4100.
Customer Service Information: Individuals interested in obtaining
[[Page 52598]]
information from the Department of Labor concerning employment-based
health coverage laws may call the EBSA Toll-Free Hotline at 1-866-444-
EBSA (3272) or visit the Department of Labor's Web site (https://www.dol.gov/ebsa). In addition, information from HHS on private health
insurance for consumers can be found on the Centers for Medicare &
Medicaid Services (CMS) Web site (https://www.cms.hhs.gov/HealthInsReformforConsume/01_Overview.asp) and information on health
reform can be found at https://www.hhs.gov/ociio/ and https://www.healthcare.gov.
SUPPLEMENTARY INFORMATION:
I. Background
The Patient Protection and Affordable Care Act (the Affordable Care
Act), Public Law 111-148, was enacted on March 23, 2010; the Health
Care and Education Reconciliation Act (the Reconciliation Act), Public
Law 111-152, was enacted on March 30, 2010. The Affordable Care Act and
the Reconciliation Act reorganize, amend, and add to the provisions of
part A of title XXVII of the Public Health Service Act (PHS Act)
relating to group health plans and health insurance issuers in the
group and individual markets. The Affordable Care Act adds section
715(a)(1) to the Employee Retirement Income Security Act (ERISA) and
section 9815(a)(1) to the Internal Revenue Code (the Code) to
incorporate the provisions of part A of title XXVII of the PHS Act into
ERISA and the Code, and make them applicable to group health plans, and
health insurance issuers providing health insurance coverage in
connection with group health plans. The Departments of Labor, Health
and Human Services, and the Treasury (the Departments) have been
issuing regulations in several phases to implement the revised PHS Act
sections 2701 through 2719A and related provisions of the Affordable
Care Act.
Section 2719 of the PHS Act applies to group health plans and
health insurance coverage that are not grandfathered health plans
within the meaning of section 1251 of the Affordable Care Act.\1\ It
sets forth standards for plans and issuers regarding both internal
claims and appeals and external review. The Departments published
interim final regulations implementing PHS Act section 2719 on July 23,
2010, at 75 FR 43330 (the interim final regulations). In general, the
interim final regulations require plans and issuers to comply with the
requirements of 29 CFR 2560.503-1 (the DOL claims procedure regulation)
and impose specified additional standards for internal claims and
appeals.
---------------------------------------------------------------------------
\1\ The Departments published interim final regulations
implementing section 1251 of the Affordable Care Act on June 17,
2010, at 75 FR 34538.
---------------------------------------------------------------------------
Section 2719 of the PHS Act provides that plans and issuers in
States without an applicable State external review process shall
implement an effective external review process that meets minimum
standards established by the Secretary through guidance and that is
similar to a State external review process described in PHS Act Section
2719(b)(1). The statute and the interim final regulations also provide
a basis for determining when plans and issuers must comply with an
applicable State external review process and when they must comply with
the Federal external review process. Generally, if a State has an
external review process that meets, at a minimum, the consumer
protections set forth in the interim final regulations, an issuer (or a
plan) subject to the State process must comply with the State process.
The regulations include a transition period for plan years (in the
individual market, policy years) beginning before July 1, 2011, during
which the Department of Health and Human Services (HHS) will work
individually with States on an ongoing basis to assist in making any
necessary changes to incorporate additional consumer protections so
that the State process will continue to apply after the end of the
transition period. For plans and issuers not subject to an existing
State external review process (including self-insured plans), a Federal
process is to apply for plan years (in the individual market, policy
years) beginning on or after September 23, 2010.
The preamble to the interim final regulations provided that the
Departments would issue additional guidance on the Federal external
review process. In addition, the preamble stated that the Departments
would issue model notices that could be used to satisfy the notice
requirements under the interim final regulations. This notice announces
the availability of and provides links to guidance on the interim
Federal external review process, as well as links to the model notices.
II. Interim Federal External Review Process for Self-Insured Group
Health Plans
This notice announces the availability of EBSA Technical Release
No. 2010-01, which provides an interim enforcement safe harbor for non-
grandfathered self-insured group health plans not subject to a State
external review process, and therefore subject to the Federal external
review process. (In the case of health insurance coverage offered in
connection with a group health plan, the issuer has primary
responsibility to comply with the interim final regulations.) This
interim enforcement safe harbor applies for plan years beginning on or
after September 23, 2010 and until superseded by future guidance on the
Federal external review process that is being developed and that will
apply after this interim period. During the period that this interim
enforcement safe harbor is in effect, the Department of Labor and the
Internal Revenue Service will not take any enforcement action against a
self-insured group health plan that complies with either of the
following interim compliance methods (and if a plan complies with one
of the interim compliance methods of this notice, no excise tax
liability should be reported on IRS Form 8928 with respect to PHS Act
section 2719(b)):
Compliance with the procedures outlined in Technical
Release 2010-01. The Department of Labor and the Internal Revenue
Service will not take enforcement action against any plan that complies
with the procedures set forth in Technical Release No. 2010-01. These
procedures are based on the Uniform Health Carrier External Review
Model Act promulgated by the National Association of Insurance
Commissioners (NAIC Model Act) in place on July 23, 2010.\2\ The
Technical Release is available today on the Department of Labor's Web
site at: https://www.dol.gov/ebsa.
---------------------------------------------------------------------------
\2\ Even though these procedures are based on the NAIC Model
Act, they do not include all the consumer protections of the NAIC
Model Act. For example, the procedures set forth in this notice do
not include the special provisions for claims relating to
experimental or investigational treatment and do not include a
government agency certifying and assigning independent review
organizations. The NAIC Model Act is available at https://www.dol.gov/ebsa and https://www.hhs.gov/ociio/. Future guidance will
address the minimum consumer protections required under the Federal
external review process after the interim enforcement safe harbor
period.
---------------------------------------------------------------------------
Voluntary compliance with State external review processes.
Alternatively, States may choose to expand access to their State
external review process to plans that are not subject to the applicable
State laws, such as self-insured plans, and such plans may choose to
voluntarily comply with the provisions of that State external review
process. In such circumstances, while the interim enforcement safe
harbor is in effect, the Department of Labor and
[[Page 52599]]
the Internal Revenue Service also will not take enforcement action
against a plan that voluntarily complies with the provisions of a State
external review process that would not otherwise be applicable or
available.
The Departments will issue guidance regarding what process will
apply under 26 CFR 54.9815-2719T(d), 29 CFR 2590.715-2719(d), and 45
CFR 147.136(d) no later than July 1, 2011 to replace the interim
process.
III. Interim Federal External Review Process for Issuers
For issuers in the individual market and the small group and large
group health insurance markets (including fully-insured group health
plans), there will be an interim enforcement safe harbor which will
apply only for plan years (in the individual market, policy years)
beginning on or after September 23, 2010 and until superseded by future
guidance on the Federal external review process that is being developed
and that will apply after this interim period. During this limited
interim enforcement safe harbor period, HHS will not take any
enforcement action against an issuer that complies with the interim
compliance method that will be detailed by HHS on the Office of
Consumer Information and Insurance Oversight Web site (https://www.hhs.gov/ociio/). This method will either involve use of a State
external appeals process or a temporary process established by HHS.
Prior to July 1, 2011, HHS will issue further guidance as to which
State external review laws have been determined to satisfy the minimum
standards of the NAIC Model Act as identified in 45 CFR 147.136(c). The
Departments will issue guidance regarding what process will apply under
26 CFR 54.9815-2719T(d), 29 CFR 2590.715-2719(d), and 45 CFR 147.136(d)
no later than July 1, 2011 to replace the interim process.
IV. Model Notices
Model notices that can be used to satisfy the disclosure
requirements of the interim final regulations \3\ are being posted on
the Department of Labor's Web site at https://www.dol.gov/ebsa and the
Department of HHS/Office of Consumer Information and Insurance
Oversight Web site at https://www.hhs.gov/ociio/. These models include:
---------------------------------------------------------------------------
\3\ For rules regarding the form and manner of notice, see 26
CFR 54.9815-2719T(e), 29 CFR 2590.715-2719(e), and 45 CFR
147.136(e).
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(1) A notice of adverse benefit determination;
(2) A notice of final internal adverse benefit determination; and
(3) A notice of final external review decision.
Model language for the description of the internal claims and
appeals and external review procedures in the summary plan description
provided to participants and beneficiaries will be posted on these
websites in the future.
Please note that the Departments accounted for the actual costs of
the external appeal process taking into account the model notices when
the interim final regulations were issued.
Signed: August 19, 2010.
Sarah Hall Ingram,
Acting Deputy Commissioner for Services and Enforcement, Internal
Revenue Service.
Signed: August 20, 2010.
Michael L. Davis,
Deputy Assistant Secretary, Employee Benefits Security Administration,
Department of Labor.
Dated: August 20, 2010.
Jay Angoff,
Director, Office of Consumer Information and Insurance Oversight.
[FR Doc. 2010-21206 Filed 8-23-10; 11:15 am]
BILLING CODE 4830-01-P; 4510-29-P; 4120-01-P
