Office of Personnel Management September 16, 2010 – Federal Register Recent Federal Regulation Documents

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 implementing regulations (codified in HHS interim final rules (IFR) at 45 CFR Part 147) require that non-grandfathered health insurance plans and issuers offering group and individual coverage have effective internal claims and appeals and external review processes. The effective date for these requirements is plan or policy years beginning on or after September 23, 2010. Regarding external review, the statute requires that health plans and issuers must comply with either a state external review process or a process meeting standards issued by the Secretary of Health and Human Services (HHS) that is ``similar to'' a state process meeting requirements in section 2719 (a ``federal external review process''). The IFR includes a transition period prior to July 1, 2011, during which time HHS will work with states to assist in making any necessary changes so that the state process will meet the minimum consumer protections identified in 45 CFR 147.136 that must be met in order for the state process to apply. During this interim period, health insurance issuers in states with external review laws in effect prior to September 23, 2010 will follow that state's external review law to the extent applicable. In states that have not passed an external review law that is in effect on September 23, 2010, a health insurance issuer must follow an interim federal external review process that will be administered by the Office of Personnel Management (OPM). The system of records will be created as OPM assists HHS by providing external reviews of adverse benefit determinations and final internal adverse benefit determinations as requested by eligible claimants and their authorized representatives (``claimants''). The system of records will include any data relevant to these external reviews, and OPM proposes to add this new system of records to its inventory of records systems subject to the Privacy Act of 1974 (5 U.S.C. 552a), as amended. This action is necessary to meet the requirements of the Privacy Act to publish in the Federal Register notice of the existence and character of records maintained by the agency (5 U.S.C. 552a(e)(4)).