January 24, 2017
On Jan. 11, 2017, CMS provided guidance outlining the requirements for group health plans and health insurance issuers that are subject to the HHS-administered federal external review process.
As background, non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual coverage must comply with the applicable external review process in their state if that process meets the standard established by the National Association of Insurance Commissioners (NAIC). If the state external review process does not meet this standard, or if the plan or issuer is not subject to state insurance regulation, then those group health plans and health insurance issuers must still implement an effective external review process meeting those same standards. The Code of Federal Regulations establishes the federal external review process for this purpose.
Insured coverage not subject to an applicable state external process and self-insured non-federal governmental plans may elect to use the federal Independent Review Organization (IRO) external review process or the HHS-administered federal external review process as outlined in the guidance.
The guidance outlines the requirements for standard external review under the HHS-administered federal external review process. Those requirements fall within the following categories:
The guidance also outlines the requirements for an expedited external review under the HHS-administered federal external review process.
Plan sponsors who are not subject to state insurance regulation or plan sponsors located in states where the state external review process does not meet the NAIC standard can use this guidance to implement the HHS-administered external process.
CMS Guidance »