The Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered plans to make two potentially significant changes to their appeal process, imposing a new requirement for an external review and making changes to the internal appeal provisions that plans already have in place. On July 22, 2010, the Departments of Treasury, Labor, and Health and Human Services jointly released Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes (IFR or Rule) under PPACA. 75 Fed. Reg. 43,330 (July 23, 2010). The IFR applies to group health plans, insurance issuers offering group health insurance coverage, and insurance issuers offering individual policies, but does not apply to grandfathered plans. (The IFR will be codified in 26 C.F.R. Parts 54 and 602, 29 C.F.R. Part 2590, and 45 C.F.R. Part 147.)

The Rule provides guidance on the new, mandatory external review process required under the PPACA and makes certain changes to the existing standards for internal claims and appeals. These changes generally will apply to plan years beginning on or after September 23, 2010 (January 1, 2011 for calendar year plans). Comments are due by September 21, 2010. Please see the attached memo for further information.


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