COMMISSIONER'S BULLETIN # B-0051-11
December 28, 2011
TO: ALL INSURANCE COMPANIES LICENSED TO WRITE HEALTH COVERAGE IN THE STATE OF TEXAS, HEALTH MAINTENANCE ORGANIZATIONS (HMOS), INDEPENDENT REVIEW ORGANIZATIONS (IROS), AND UTILIZATION REVIEW AGENTS CONDUCTING UTILIZATION REVIEW FOR A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY (URAS)
RE: TEMPORARY STANDARDS APPLICABLE TO THE TEXAS EXTERNAL REVIEW PROCESS
This bulletin notifies health insurance issuers, HMOs, IROs, and URAs in Texas of the impact of the U.S. Department of Health & Human Services' (HHS) Technical Release 2011-02 on external review processes. A copy of Technical Release 2011-02 is attached and a link to the document is as follows: http://cciio.hhs.gov/resources/files/appeals_srg_06222011.pdf.
Technical Release 2011-02 establishes a set of temporary standards for NAIC-similar external review processes that will apply until January 1, 2014. If all HMOs and health insurance issuers offering health coverage in Texas in the individual and group health market voluntarily comply with these temporary standards, Texas will maintain its external review process through an NAIC-similar designation by HHS.
The Patient Protection and Affordable Care Act, Public Law 111-148, was enacted on March 23, 2010; the Health Care and Education Reconciliation Act, Public Law 111-152, was enacted on March 30, 2010 (collectively, "the PPACA"). The PPACA reorganizes, amends, and adds to the provisions of part A of Title XXVII of the Public Health Service Act ("part A" of "the PHS Act") relating to group health plans and health insurance issuers offering group and individual health insurance coverage.
The PPACA adds section 715(a)(1) to the Employee Retirement Income Security Act (ERISA) and section 9815(a)(1) to the Internal Revenue Code (the Code) to incorporate the provisions of part A into ERISA and the Code. As a result, part A applies to group health plans and health insurance issuers providing health insurance coverage in connection with group plans.
HHS and the U.S. Department of Labor and the U.S. Department of the Treasury (collectively, "Departments") published interim final rules implementing section 2719 of the PHS Act on July 23, 2010. An amendment to the interim final rules was published on June 24, 2011, and Technical Release 2011-02 was released simultaneously with the amendment. Section 2719 of the PHS Act applies to group health plans and health insurance issuers in the individual and group health insurance markets that are not grandfathered health plans.
The attached Technical Release 2011-02 establishes minimum standards for NAIC-similar processes that will temporarily apply to a state-administered external review process. These 13 temporary standards will apply to HMOs, health insurance issuers (and, if applicable, self-insured nonfederal governmental plans) in Texas until January 1, 2014.
Temporary Standards for NAIC-similar
States must meet all of the temporary standards for a State-administered external review process to be considered to have an NAIC-similar process. Texas' external review process meets all 13 temporary standards listed in the attached HHS Technical Release 2011-02 except for Numbers 4 and 13. Temporary standard Number 4 requires that if exhaustion of internal appeals is required prior to external review, this exhaustion of internal appeals must not be necessary if: (a) the internal appeal process timelines are not met; or (b) in an urgent care situation, the claimant files for an external review before exhausting the internal appeal process. Temporary standard Number 13 requires expedited external review of urgent care claims; this requires the IRO to inform the issuer and the claimant of an urgent care decision within four business days or less from receipt of the request for review and provide written notice of its decision within 48 hours of the oral notification.
Preserving Texas' oversight for external review will ensure consistency across a variety of health products, creating more uniformity and less consumer confusion for both issuers and consumers. Voluntary compliance with these standards will ensure this consistency. If HMOs and health insurance issuers in Texas do not voluntarily comply with the additional temporary standard Numbers 4 and 13, the law requires Texas health coverage issuers to participate in a federally administered external review process as described, starting at page seven of the attached Technical Release 2011-02.
Questions regarding this bulletin should be directed to LHLMgmt.TITAN.TDI@tdi.state.tx.us.
Commissioner of Insurance
Attachment: HHS Technical Release 2011-02
For more information contact:
Last updated: 09/28/2015