Health Plans, Insurers Get Limited & Imperfect Relief From Grace Period Extension For Some New Affordable Care Act Health Claims & Appeals Rules

March 24, 2011

 The Departments of Labor, Health & Human Services and Internal Revenue Service are extending a previously announced enforcement grace period under which the agencies will not take enforcement against health plans or health insurers that attempt to operate in good faith compliance with, but fail to meet certain new requirements for handing medical claims and appeals enacted as part of the Patient Protection and Affordable Care Act (Affordable Care Act).  While health plans and insurers working in good faith to comply with the new requirements may find the enforcement relief helpful for dealing with some areas of uncertainty about the interpretation of certain requirements, it is important to keep in mind that the enforcement grace period provides only limited and somewhat imperfect relief.  As a result, health plans, health insurers and those responsible for their design and administration are encouraged to continue to move forward on efforts to comply with the new requirement in thoughtful and well-documented manners despite the announced grace period extension.

New Claims & Appeals Requirements & Enforcement Grace Period

As signed into law on March 23, 2010, the Affordable Care Act generally requires that health plans and health insurance policies that are not “grandfathered” to begin complying with a series of new requirements by the first day of the first plan year that begins after September 22, 2010.  These new requirements include a number of new requirements about the way that nongrandfathered health plans and health insurance policies handle medical claims and appeals.  For instance, the Affordable Care Act as construed by the agencies in interim final regulations published by the agencies on July 23, 201 will require that non-grandfathered group health plans and insurers issuing non-grandfathered health insurance plans and policies:

  • Implement specified internal and external review procedures that among other things mandate independent external review of medical judgment based decisions in accordance with the regulations for reviews of appeals of medical judgment based denials;
  • Provide a broad range of new information in notices regarding claims and do so in a culturally and linguistically appropriate manner;
  • Provide continued coverage pending the outcome of an internal appeal; and
  • Comply with a laundry list of additional criteria for ensuring that a claimant receives a full and fair review in addition to complying with the requirements of existing Labor Department claims and appeals procedures.

After the agencies jointly published interim final regulations defining and implementing these requirements on July 23, 2010, last September the agencies announced that they would not enforce certain elements (but not all) of the new requirements set forth in the interim final regulations against covered health plans or health insurers seeking to comply in good faith with the new requirements through July 1, 2011.  In the March 18, 2011 announcement, the Department of Labor said that the agencies now have agreed to extend this reprieve from agency enforcement of the requirements listed in the guidance against plans seeking to comply in good faith with the new requirements until plan years beginning on or after January 1, 2012.

While offering welcome relief, covered health plans and insurers, their sponsors and issuers should not over-estimate the reach and protection provided by this new guidance.  For instance:

  • First, in order to qualify for the enforcement grace period, efforts must be made to administer the health plan or health insurance policy in good faith compliance with the new requirements during the enforcement grace period. 
  • Second, the enforcement grace period provides only limited relief.  The extension to 2012 only four of a series of new requirements set forth in the interim final regulations.  Nongrandfathered plans and their administrators and insurers remain accountable for prudently administering claims and appeals in accordance with all other requirements of the Affordable Care Act as well as pre-existing claims and appeals regulations set forth in 2000 claims regulations issued by the Department of Labor pursuant to the Employee Retirement Income Security Act.
  • Third, the enforcement grace period guidance only means that the agencies will not exercise their power to take action against a non-compliant plan.  It does not prevent plan members, health care providers with benefit assignments or other plan beneficiaries from bringing lawsuits against health plans, health insurers or their administrators for failing to comply with the new requirements during post- September 22, 2010 plan years even if the enforcement grace period otherwise protects the plan or insurer from agency enforcement action.  This means that health insurers and health plans may still run the risk that plan members or beneficiaries will ask courts to reverse claims or appeals denials or impose other penalties and sanctions against plans or their fiduciaries for failing to meet the new requirements for post-September 22, 2010 plan years.
  • Finally, and perhaps most significantly, the grace period guidance requires nongrandfathered plans and insurers to make “good faith” efforts to comply with the requirements covered by the relief during the grace period in order to be eligible to claim the relief offered by the enforcement grace period guidance.

Consequently, despite the relief announced March 18, nongrandfathered health plans still have significant work to do to comply with the new Affordable Care Act claims and appeals requirements even during the announced enforcement grace period.

For Help With Affordable Care Act or Other Employee Benefits or HR Needs

If you have any questions or need help responding to the Affordable Care Act or other any other health plan or insurance employee benefit, compensation, workforce or internal control concerns, please contact the author of this update, Cynthia Marcotte Stamer here or at (469)767-8872.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here.

©2011 Cynthia Marcotte Stamer.  Non-exclusive right to republish granted to Solutions Law Press.  All other rights reserved.


EEOC Finalizes Updates To Disability Regulations In Response to ADA Amendments Act

March 24, 2011

Employers Urged To Tighten Disability Related Discrimination Risk Management

Employers should review and update their existing employment and employee benefit practices in response to updated regulations (Final Regulations) governing the disability discrimination rules of the Americans With Disabilities Act as amended by the ADA Amendments Act (ADAAA) that the Equal Employment Opportunity Commission (EEOC) will publish in the Friday, March 25, 2011 Federal Register.

On Thursday, March 24, 2011, the EEOC released an advance copy of the Final Regulations along with two Question-and-Answer documents about the Final Regulations to aid the public and employers – including small business – in understanding the law and new regulations. The Final Regulations, accompanying Question and Answer documents and a fact sheet are available on the EEOC website here .

The changes contained in the updated Final Regulations update the EEOC’s disability regulations in response to amendments made to the ADA by Congress as part of the ADAAA.  Like the ADAAA they implement, the Final regulations are designed to simplify the determination of who has a “disability” and make it easier for people to establish that they are protected by the Americans with Disabilities Act (ADA).

The Final Regulations and the ADAAA amendments they implement make it likely that businesses generally will face more disability claims from a broader range of employees and will possess fewer legal shields to defend themselves against these claims. Since these changes make it easier for certain employees to qualify as disabled under the ADA, businesses should act strategically to mitigate their ADA exposures in response to the Final Regulations.  Learn more about the Final Regulations and get suggestions for risk management of expanding disabilities discrimination exposures here.

For Help With Disability Discrimination Risk Management or Other Needs

If you need assistance in auditing or assessing, updating or defending your disability management or with other labor and employment, employee benefit, compensation or internal controls practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer is nationally and internationally recognized for more than 23 years of work helping employers; employee benefit plans and their sponsors, administrators, fiduciaries; employee leasing, recruiting, staffing and other professional employment organizations; and others design, administer and defend innovative workforce, compensation, employee benefit  and management policies and practices. Her experience includes extensive work helping employers implement, audit, manage and defend wage and hour and other workforce and internal controls policies, procedures and actions.  The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer works, publishes and speaks extensively on wage and hour, worker classification and other human resources and workforce, employee benefits, compensation, internal controls and related matters.  She also is recognized for her publications, industry leadership, workshops and presentations on these and other human resources concerns and regularly speaks and conducts training on these matters. Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, and many other national and local publications. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here .

 ©2011 Cynthia Marcotte Stamer.  Non-exclusive right to republish granted to Solutions Law Press.  All other rights reserved.


Speak Up On The 1st Anniversary of Health Care Reform

March 23, 2011

On the 1st anniversary of the passage of Health Care Reform,  let’s celebrate by accepting the invitation from Joe Biden to “discuss how health care reform is already working.”

Below is the text of an e-mail I (and millions of other Americans, I suspect, received an e-mail from Joe Biden, in which he touts health care reform  as already saving patients like a young man from Minnesota.  In the e-mail, Biden says:  “On the one-year anniversary of the Affordable Care Act, I think we have a duty to discuss how reform is already working.”  OK, tell me what you think?

Unquestionably, health care reform produces some winners and loosers.  Although few of the reforms enacted are actually in effect yet, Biden says heath care reform is working and credits the law for saving the life of the young man and millions of others.   On the other hands, many patients and doctors treating patients with cancer and other life threatening illnesses complain and report fears that in the future increasing Medicare, Medicaid or other government regulations and market distruptions.    Some folks think it’s all good.  Other’s think it’s all bad.  Many American’s think it’s a little bit of both and many just don’t know.

Where does the truth lie?  On the 1st anniversary of the passage of health are reform, one thing is certain.  The American health care system and it’s impact on our employees, families, friends, communities and goverment and personal budget’s is too great to be complacent.  So, as Health Care Reform turns one, let’s accept the invitation of Vice President Biden and share our experiences and thoughts with our elected representatives, regulators,  with others on with others on the Coalition for Responsible Health Care Policy linkedin a the following link and keep the discussion going until we get it right:   

Coalition for Responsible Health Care Policy 

Here’s the e-mail from “Joe Biden [info@barackobama.com]“

Cynthia –I want to tell you about a family in Minnesota.

Justin and Kari live in Brooklyn Park, right outside of Minneapolis. They’re parents to three children. Their three-year-old, William, was born with a genetic disorder called tuberous sclerosis complex.

For the rest of his life, William will wrestle with tumors in his brain, his heart, his kidneys, his skin, and possibly other major organs. He must take medication to control seizures and faces the threat of kidney disease.

What Justin and Kari want for William is a future. And because of health reform, that’s what he’ll have.

Today, insurance companies are no longer able to discriminate against William because of the condition he’s dealt with since birth. Now, Justin and Kari know they’ll be able to get the kind of care that William needs — today and into the future.

Their story isn’t unique, but it’s one of many that need to be told. We all know people whose lives have been changed because of the Affordable Care Act, even if we don’t realize it. So we’ve found a way to show exactly how reform is working for all of us — for our parents, our siblings, our kids, ourselves.

Will you take a minute to take our Health Reform Checkup and let the people you love know how reform is working for them?

Before the Affordable Care Act, Justin and Kari weren’t sure about the future. They worried that they’d never be able to find coverage for William again if Justin lost his job. They worried about the life that William would lead — whether he’d ever be able to work or support a family.

Not anymore. William’s condition isn’t going away, but he’ll always be able to get care. The Affordable Care Act is one year old today, and it has already changed William’s life — and this country — for good.

Today, there are families who feel better about the future than they did a year ago. They’ve found some security, some relief. And these are people we know. They’re our neighbors, our colleagues, our friends, our families — the people next to us every day.

On the one-year anniversary of the Affordable Care Act, I think we have a duty to discuss how reform is already working.

Watch Justin and Kari tell their story, and take a moment to learn how health reform is changing the lives of those you know:

 

 

A year ago, I stood next to the President as he signed health reform into law — and we have you to thank for making that possible.

 

  

Yours,

 

Joe

Right-click here to download pictures. To help protect your privacy, Outlook prevented automatic download of this picture from the Internet.

Paid for by Organizing for America, a project of the Democratic National Committee — 430 South Capitol Street SE, Washington, D.C. 20003. This communication is not authorized by any candidate or candidate’s committee.

 

H


Employer Pays $754,578 To Settle Charges Workers Misclassified & Underpaid In Violation of FLSA

March 11, 2011

Beck Disaster Recovery Inc. (Beck) will pay $754,578 in overtime back wages to 89 current and former temporary field supervisors to settle U.S. Department of Labor Wage & Hour Division (DOL) charges that that the company violated the Fair Labor Standards Act (FLSA) by improperly classifying workers as exempt from the Fair Labor Standards Act and failed to pay the workers for all compensable hours worked.  Another of the mounting series of DOL overtime and wage and hour enforcement actions arising from employer misclassification of workers, the Beck settlement and other recently reported DOL enforcement actions demonstrate the significant risks that employers can incur if caught mischaracterizing or underpaying non-exempt employees. See e.g. $1 Million + FLSA Overtime Settlement Shows Employers Should Tighten On-Call, Other Wage & Hour Practices

FLSA & Beck Settlement

The FLSA generally requires that employers pay covered employees at least the federal minimum wage of $7.25 per hour for all hours worked, plus time and one-half their regular rates of pay, including commissions, bonuses and incentive pay, for hours worked beyond 40 per week.  Under existing FLSA regulations, covered employees generally include all common law employees other than those employees that the employer proves qualify as exempt.  Employers also generally maintain accurate time and payroll records.  Improper classification of workers as exempt from FLSA coverage, inadequate recordkeeping, or mischaracterization of compensable hours of work as non-compensable exposes an employer to significant minimum wage, overtime and recordkeeping violations.  Misclassification often occurs because an employer improperly treats a worker that it recognizes to be its employee as an “exempt” employee and pays the employee on a salaried or other basis inconsistent with the FLSA, because the employer treats a worker as not its employee when that worker qualifies as its employee under applicable common law tests of the existence of an employment relationship, or a combination of both of these circumstances. 

The Beck settlement announced by DOL on March 10, 2011 resolves charges that its misclassification of certain regular and temporary workers as exempt employees lead Beck to violate the FLSA in several respects. Beck provides emergency preparedness and natural disaster response services to public and private sector organizations nationwide. While its corporate offices are in Florida, and the company also maintains offices in California, Indiana, Louisiana, Massachusetts., New York, Texas, and the District of Columbia. Employees travel to natural disaster sites nationwide as needed.  In addition to denying several misclassified employees overtime compensation earned for hours over 40 in a week, the DOL charged that Beck also failed to provide paid leave as required to certain of these misclassified employees.  Under the FLSA, employees claimed as exempt must receive a fixed salary that may not be reduced based on the quality or quantity of the work performed.

To resolve the DOL charges, Beck has agreed under the settlement to pay the full amount of back wages, properly classify its temporary employees as nonexempt from the FLSA and maintain future compliance with the law.

DOL Enforcement Demonstrates Risks For Business

The Beck settlement and other recently reported enforcement actions send a strong signal to employers of the advisability of auditing the defensibility of their classification of workers as exempt, contractors or non-employees, and taking other steps to strengthen the defensibility of their overtime, recordkeeping, and other wage and hour practices.   In recent months, DOL enforcement actions against misclassification of workers as exempt employees or treatment of contract or leased employees as non-employees have resulted in several back pay awards by several employers of more than $1 million and many others of several hundreds of thousands of dollars. $1 Million + FLSA Overtime Settlement Shows Employers Should Tighten On-Call, Other Wage & Hour Practices As the same conduct often also violates state wage and hour laws, offending employers also may face back pay and other awards from actions brought by state officials and employee lawsuits. Employers and others providing workforce staffing should review and tighten existing worker classification, timekeeping and classification, recordkeeping and other practices and take other steps to strengthen the defensibility of their practices.

Learn more about the DOL’s FLSA enforcement actions and tips for managing FLSA and other wage and hour risks here.

For Help With Wage & Hour or Other Needs

If you need assistance in auditing or assessing, updating or defending your wage and hour or with other labor and employment, employee benefit, compensation or internal controls practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer is nationally and internationally recognized for more than 23 years of work helping employers; employee benefit plans and their sponsors, administrators, fiduciaries; employee leasing, recruiting, staffing and other professional employment organizations; and others design, administer and defend innovative workforce, compensation, employee benefit  and management policies and practices. Her experience includes extensive work helping employers implement, audit, manage and defend wage and hour and other workforce and internal controls policies, procedures and actions.  The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer works, publishes and speaks extensively on wage and hour, worker classification and other human resources and workforce, employee benefits, compensation, internal controls and related matters.  She also is recognized for her publications, industry leadership, workshops and presentations on these and other human resources concerns and regularly speaks and conducts training on these matters. Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, and many other national and local publications. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

 ©2011 Cynthia Marcotte Stamer.  Non-exclusive right to republish granted to Solutions Law Press.  All other rights reserved.


CMS Publishes Proposed Consumer Disclosure Notices Detailing Required Health Insurer Rate Increase Justification Disclosures

March 7, 2011

 The Centers for Medicare & Medicaid Services (CMS) on March 7, 2011 published proposed consumer disclosure notices that it proposes to require insurers proposing rate increases over 10 percent to electronically file in furtherance of CMS’ implementation of the Affordable Care Act premium rate review regulation published by HHS in December of 2010.  The proposed consumer disclosure notices can be found here listed under “CMS-10379.”

Like the premium rate review regulation, the proposed notification requirements would apply to non-grandfathered group or individual insurance plans in the individual and small group markets.

Under the premium rate review regulation, rate increases by insurers for non-grandfathered group or individual health insurance plans that exceed a specified threshold amount are subject to review by either State insurance officials or HHS if the State does not have an effective process for reviewing rates.  The proposed threshold for the first year is 10%.  After 2011, a state-specific threshold will be set for disclosure of rate increases, using data and trends that better reflect cost trends particular to that state.  According to CMS’, the review of rates under the rate review regulation could begin as early as July 2011.

CMS contemplates that the proposed consumer disclosure notices published March 7, 2011 will ‘help consumers know what their insurance companies are proposing while the rate increase requests are being reviewed.  The notices would provide some basic information about health insurance rate increases and their review, as well as detailed information about the specific increase that an insurer has proposed. Consumers would also be able to see what the insurance company believes is driving the increase in premiums and how much of the increase would go to profits and administrative expenses. CMS intends to make the information provided by insurers in the notices available to consumers on CMS’ website.  According to CMS, once rates begin being reviewed, HHS will work to post information on proposed rates as quickly as possible.

For Help Responding To Affordable Care Act or Other Health Plan Rules

The proposed premium rate review and associated consumer disclosure notice requirements are part of the rapidly evolving federal and state rules, court decisions, enforcement actions and other developments that require quick action by health plans, health insurers and their sponsors and administrators.  If you need assistance in auditing or assessing, updating or defending your health plan or policies, documents, practices or conduct, or other labor and employment, employee benefit, compensation, privacy and data security, or other related practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer works, publishes and speaks extensively on Affordable Care Act and other health and other employee benefit, insurance, human resources and health care matters.

Nationally and internationally known for her leading edge work on health benefit and insurance matters, Ms. Stamer has counseled, represented and trained employers and other employee benefit plan sponsors, plan administrators and fiduciaries, insurers and financial services providers, third party administrators, human resources and employee benefit information technology vendors and others privacy and data security, fiduciary responsibility, plan design and administration and other compliance, risk management and operations matters for more than 23 years.  She also is recognized for her publications, industry leadership, workshops and presentations on health benefit reform and other related health and pension, human resources, insurance, privacy and health care concerns.  She also regularly conducts training on these and other related matters for a broad range of organizations including the Association of State and Territorial Healthcare Organizations (ASTHO), the Los Angeles County Health Department, a multitude of health plans and their sponsors, health care providers, the American Bar Association, SHRM, the Society for Professional Benefits Administrators and many others Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, and many other national and local publications. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

©2011 Cynthia Marcotte Stamer.  Non-exclusive right to republish granted to Solutions Law Press.  All other rights reserved.


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