External Reviews and the Patient Protection and Affordable Care Act

THE GREAT SEAL OF THE STATE OF UTAH 1896 State of Utah GARY R. HERBERT Governor GREG BELL Lieutenant Governor D. KENT MICHIE Insurance Commissioner Insurance Department # Bulletin 2010-9 To: All Health Insurance Issuers and Group Health Plans, Including Self-Funded Health Plans From: Neal T. Gooch, Utah Insurance Commissioner Date: December 2, 2010 Subject: External Reviews and the Patient Protection and Affordable Care Act. The purpose of this bulletin is to expand access of the State of Utah's external review process to non-grandfathered health insurance issuers and group health plans, including self-funded health plans. The Patient Protection and Affordable Care Act, Public Law 111-148, as amended, requires that a group health plan and a health insurance issuer offering group or individual health insurance coverage must comply with a state's external review process if that process includes, at a minimum, the consumer protections set forth in 29 CFR 2560.503-1. The Utah Insurance Department (UID) external review process is contained in Utah Code Annotated §31A-22-629, Adverse Benefit Determination Review Process, and Utah Administrative Code Rule R590-203, Health Grievance Review Process and Disability Claims. Rule R590-203 requires compliance with 29 CFR 2560.503.1. The Patient Protection and Affordable Care Act now extends the UID external review process to self-funded health plans. The Department of Health and Human Services (HHS) has reviewed the Utah external review process and determined that it is compliant with HHS requirements. Each group health plan and health insurance issuer should review their external review practices and procedures to assure compliance with the law. DATED this 2nd day of December 2010. Neal T. Gooch Neal T. Gooch Insurance Commissioner State Office Building Suite 3110, Salt Lake City, UT 84114-6901 • (801) 538-3800 • Facsimile (801) 538-3829 • www.insurance.utah.gov