Problematic Health Insurance Reform One Year Anniversary

Senate Finance Republicans are using the one-year anniversary of the PPACA to question Health and Human Services (HHS) Secretary Kathleen Sebelius on what they call the administration’s lack of transparency in the law’s implementation.  During a Senate Finance Committee hearing, Sen. Orrin Hatch (R-UT) said that the Congressional Research Service (CRS) has found that Sebelius has the authority to waive the PPACA’s maintenance-of-effort requirement penalizing states whose Medicaid enrollment levels drop below where they stood when the law was enacted. Sebelius had previously told governors, in response to their requests that she waive the requirement, that she would continue to review whether she had the authority to do so. Sen. Charles Grassley (R-IA) asked the Secretary why Iowa and other states shouldn’t be allowed to establish their own medical loss ratio (MLR) standards, given that HHS recently granted a waiver exempting the individual health insurance market in Maine from the federal MLR. Secretary Sebelius said that Maine is unique because only two insurers currently offer coverage in that state’s individual health insurance market. She added that HHS is continuing to listen to state regulators across the nation.

After a lengthy discussion with the private sector, including Aetna health insurance, the Department of Labor has issued favorable guidance on government enforcement of certain internal claims and appeals rules as originally authorized under PPACA.  The current grace period, which runs out in July of this year, has now been extended to plan years beginning on or after January 1, 2012 with respect to four key areas of major insurer and employer concern, including the cultural and linguistic notice requirements, disclosure of treatment and diagnostic codes and their descriptions to members, the urgent care turnaround timeframe for initial requests, and the strict compliance standard. Aetna health insurance is concerned that these requirements could be confusing to members and will be costly and burdensome. These requirements are no longer subject to a good faith implementation requirement during the enforcement grace period, and the DOL has indicated that an amendment will be issued to the original 2010 interim final regulations in this area. For the rules on which the enforcement grace period expire in July (i.e., other required notices on statements of adverse determinations), implementation will take effect on plans written or renewed beginning July 1, 2011.

External review standards continue to be discussed. HHS is expected to issue future guidance on whether a state external review process meets the federal standard for external review.  The scope of federal external review process (for self funded, or the federal-operated process applicable to certain insured business) was not addressed by this guidance but may be addressed in the future.

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