Health Insurance Form Filing Submission Guidelines For Revised Internal and External Appeals Processes

STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-82 MAY11,2011 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE INDIVIDUAL AND GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT SUBJECT: HEALTH INSURANCE FORM FILING SUBMISSION GUIDELINES FOR REVISED INTERNAL AND EXTERNAL APPEALS PROCESSES The Connecticut Insurance Department is seeking legislative changes to bring the state requirements for external appeals into compliance with the requirements set forth in the federal Patient Protection and Affordable Care Act, Pub.L.111-148, as amended by the Health Care and Education Reconciliation Act of2010, Pub. L. 111-152 (collectively "PPACA"). PPACA requires that a health insurance issuer offering group or individual health insurance coverage comply with the applicable state process that at a minimum includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association ofInsurance Commissioners (NAIC) and is binding on such plans. The proposed legislation also modifies the requirements for internal appeals and utilization review to conform to PPACA requirements that health insurance issuers must follow. The details of the revised state external appeals, internal appeals, and utilization review processes will be set forth in a separate bulletin. Effective July 1, 2011, all health insurance issuers will need to provide enrollees with an endorsement that amends existing contracts, detailing the revised internal and external appeals processes. To ensure health insurance issuers can meet the July I, 20 II effective date, the proposed legislation includes a provision for such filings to be exempt from the prior approval requirements of Connecticut General Statutes Sections §38a-183, §38a-481 and §38a-513. If the legislation passes, health insurance issuers must file such endorsements with the Insurance Department by July 1, 2011 and may use them upon filing. Such filing must include a cover letter that lists the previously approved forms for which this endorsement will be used as well as a certification signed by an officer of the company that such filing is in compliance with requirements of PPACA regarding appeals. In the event the proposed legislation is not enacted, carriers will still need to file endorsements with the Insurance Department to amend existing internal and external appeals language to conform to and evidence compliance with the federal appeals processes. No certification would be required as such filings would be subject to prior approval under existing statutes. The filings will be given priority processing to facilitate compliance as of July 1,2011. Please contact the Insurance Department Life and Health Division at cid.lh@ct.gov with any questions. ;L~, Thomas B. Leonardi Insurance Commissioner www.ct.gov/cid P.O. Box 816 • Hartford,CT06142-0816 An Equal Opportunity Employer