Free 8/13 ABA RPTE Study Group Call On Affordable Care Act Claims & Grandfathered Plan Regulations

August 8, 2010

On August 13, 2010, at  1 PM Eastern, Noon Central, 11 AM Mountain and 10 AM Pacific, the RPTE Employee Benefits Group will host a free one hour “Study Group” conference call led by the Welfare Plan Committee to discuss the interim regulations under the Patient Protection and Affordable Care Act (PPACA) regarding claims adjudication and grandfather plan status.  This timely discussion has immediate impact on practitioners and their clients dealing with group health plans, since the new rules generally apply to plan years beginning on or after September 23, 2010.

Key topics will include:

  • Mandatory Claims Processing and Appeals Process Requirements
  • Impact on 2001 ERISA Claims Regulations
  • Impact on Plan Designs and Plan Administration
  • Determining Grandfather Status
  • Impact of Future Plan Actions on Grandfather Status

In addition, the topics for possible future calls in September and October regarding health care reform, as well as the current ABA projects to provide comments to the DOL, IRS and Department of HHS with respect to guidance under PPACA and opportunities for involvement also will be discussed.

The conference call will be moderated by:

  • Cynthia Marcotte Stamer, Cynthia Marcotte Stamer, PC, Dallas, TX;
  • Elizabeth Leight, Society of Professional Benefit Administrators, Washington, DC; and
  • Scott Douglas Marquardt, Total Plan Services, Inc., Dallas, TX

The phone number and passcode for the call are:

(866) 646-6488

Pass code: 5380700259

Given the scope of the changes wrought by PPACA, and the numerous interpretations being offered in the legal and insurance communities as well as the media, this promises to be a lively discussion.  Multiple views and comments are encouraged.

Other Resources

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

ü     Small Employers Sponsoring Health Coverage May Qualify For New Tax Credit, Must Act Quickly To Comply With Other New Federal Health Plan Mandates Under Affordable Care Act & Other Laws

ü     Rite Aid Pays $1 Million HIPAA Privacy Settlement As OCR Tightens HIPAA Regulations

ü     New Affordable Care Act Mandated High Risk Pre-Existing Condition Insurance Pool Program Regulations Prohibit Plan Dumping of High Risk Members, Set Other Rules

ü     Register Now For 8/24 2010 Health Plan Update Briefing

ü     Congress & Labor Department Considering Tightening of Retirement Plan Regulations

ü     Testimony Highlights Growing Exposure of Businesses Misclassifying Workers; Businesses Should Act to Minimize Risks

ü     Businesses Employing Children Should Review & Tighten Practices In Light of Tightened Rules & Increased Penalties

ü     New Affordable Care Act Health Plan Appeals Regulations Require Health Plan Updates

ü     Blockbuster & Health Delivery Disability Discrimination Settlements Highlight Need For Tightened Disability Discrimination Risk Management

ü     Agencies Release Regulations Implementing Affordable Care Act Health Plan Preventative Care Mandates

ü     New Retirement Plan Resource To Help Spanish-Speaking Participants With Retirement Planning

ü     Office of Civil Rights Proposes Changes To HIPAA Privacy, Security & Civil Sanctions Rules

ü     St. Louis Employer’s OSHA Violations Trigger Contempt Order and Penalties

ü     Review & Strengthen Defensibility of Existing Worker Classification Practices In Light of Rising Congressional & Regulatory Scrutiny

ü     Key Affordable Care Act Health Plan Coverage Mandates Guidance Issued June 28; Apply ASAP For Early Retirement Reinsurance Program

ü     HHS, DOL & IRS Rules Define “Grandfathered” Group Health Plans & Health Insurance Coverage under the Patient Protection and Affordable Care Act

ü     New Rule Requires Federal Government Contractors To Post New “Employee Rights Under The National Labor” Poster

ü     Defined Contribution Plans Investing In Publically Traded Employer Securities Face New Requirements

ü     CBO Raises Estimated Cost of Health Care Reforms As Employers, Health Plans Brace Costs Of Newly Effective & Impending Mandates

ü     Certain Workforce Reductions Trigger Plant Closing Notice & Other Obligations

ü     Mishandling Employee Benefit Obligations Creates Big Liabilities For Distressed Businesses & Their Business Leaders

ü     DOL Plans To Tighten Employment Protections For Disabled Veterans & Other Disabled Employees Signals Need For Businesses To Tighten Defenses

ü     COBRA, HIPAA, GINA, Mental Health Parity or Other Group Health Plan Rule Violations Trigger New Excise Tax Self-Assessment & Reporting Obligations

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, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review here. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here.

©2010 Solutions Law Press. All rights reserved.


HHS, DOL & IRS Rules Define “Grandfathered” Group Health Plans & Health Insurance Coverage under Affordable Care Act

June 15, 2010

Affordable Care Act Health Plan Guidance Update Teleconference Briefing Planned July 9

The U.S. Departments of Health and Human Services, Labor and Treasury on Monday (June 14, 2001) published regulations on when group health plans and insurance qualify as “grandfathered plans” for purposes of determining certain deadlines for complying with certain health care reform requirements imposed under the Patient Protection & Affordable Care Act (Affordable Care Act).  

The regulations are the latest in a series of emerging guidance that federal agencies have issued regarding the Affordable Care Act since its enactment in March, 2010. Solutions Law Press author Cynthia Marcotte Stamer will host a teleconference briefing on these new regulations and other Affordable Care Act health plan guidance on July 9, 2010 from 11:30 a.m. to 1:30 p.m. Central Time.  E-mail here to request an invitation and registration information.

While the Affordable Care Act  generally will require that all health plans provide new mandated benefits and other rights to covered persons beginning with plan years starting after September 22, 2010, health plans that existed on March 23, 2010 that qualify as “grandfathered” are exempt from some new requirements.  The regulation published yesterday specifies what health plans must do to qualify for grandfathered status for purposes of these requirements. 

As part of its first wave of health insurance reforms, the Affordable Care Act dictates that all health plans – whether or not they are grandfathered plans –  provide certain benefits to their covered persons for plan years starting on or after September 23, 2010 including:

  • New restrictions on lifetime limits on essential benefit coverage;
  • No rescissions of coverage when people get sick and have previously made an unintentional mistake on their application; and
  • Extension of parents’ coverage to young adult children under 26 years old.

For post September 22, 2010 plan years, non-grandfathered plans also generally must  meet certain other conditions including:

  • No coverage exclusions for children with pre-existing conditions;
  • No “restricted” annual limits set by regulations to be issued in the future;
  • Coverage of recommended prevention services with no cost sharing;
  • Patient protections such as access to OB-GYNs and pediatricians without a referral by a separate primary care provider;
  • Greater freedom for patients to obtain certain emergency treatment without certain plan restrictions; and
  • Other requirements.

Under the Affordable Care Act, grandfathered plans are exempt from certain of these mandates and may enjoy delayed compliance deadlines for certain other requirements.

The grandfather rule published June 14 provides certain “routine changes” will not cause a health plan that existed on March 23, 2010 to give up grandfathered status.  Allowable changes include cost adjustments to keep pace with medical inflation, adding new benefits, making modest adjustments to existing benefits, voluntarily adopting new consumer protections under the new law, or making changes to follow State or other Federal laws. For this purpose, the regulation states that premium changes are not taken into account when determining whether or not a plan is grandfathered.

On the other hand, the regulation provides that a health plan that existed on March 23, 2010 will lose its eligibility for grandfathered status if the plan is amended to make significant changes that cut benefits or increase costs to covered persons.

Furthermore the regulation also addresses the effect of mergers and acquisitions and various other events and amendments on the eligibility of health plans for grandfathered status.

You can view the regulation here.  Details about what routine changes insurers and employers can make without losing their grandfathered status, and the projected impact on large and small employer plans and the individual plan market can be found here.  A fact sheet about the regulation can be found here.  You can read the Questions and Answers on the Regulation here.

If you need help reviewing or responding to this or other health benefit regulations or other related matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

About Ms. Stamer

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 employer and other plan sponsors, insurers, administrators, fiduciaries, governments and others design, administer and defend innovative health and other employee benefit programs and other human resources, compensation and management policies and practices.

As a core focus of her practice, Ms. Stamer works extensively with employer and other health plan sponsors, fiduciaries, administrative and other service providers, insurers, and other clients on health benefit program and product design, documentation, administration, compliance, risk management, and public policy matters.  The publisher of Solutions Law Press, Ms. Stamer also publishes, conducts training and speaks extensively on these and related concerns for the ABA, the Bureau of National Affairs and many other organizations.  Please join us for what promises to be a most interesting discussion.

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, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, and the editor and publisher of Solutions Law Press HR & Benefits Update and other Solutions Law Press Publications, Ms. Stamer also is recognized for her publications, industry leadership, workshops and presentations on these and other health industry and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience hereHer insights on these and other matters appear in Managed Care Executive, Modern Health Care, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, MDNews, Kentucky Physician, and many other national and local publications. 

If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer 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 here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.    If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject to here.

©2010 Solutions Law Press. All rights reserved.