Insights

Transition to Federal External Review Process


On Jan. 10, 2018, the Texas Department of Insurance (TDI) issued Commissioner’s Bulletin # B-0001-18, indicating that Texas would no longer provide external review for certain plans. As background, the ACA required additional external review of certain claims. However, ACA allowed for a temporary period during which states could impose their own external review requirements (if they were inconsistent with the ACA requirements). That temporary period has ended, and Texas won’t change its external review process to the process imposed by federal law. So health insurance plans that are subject to the ACA external review requirements will now go through federal external review instead of the external review provided by Texas.

As part of the transition to federal review, insurers will need to comply with certain deadlines. Specifically, insurers have until Feb. 16, 2018 to inform CMS of the external review process they intend to use; until March 31, 2018 to submit updated notices, policies or plan documents, and adverse benefit determination notices to CMS or TDI for review; and until June 30, 2018 to send notices and updated plan documents to participants. June 30, 2018 is the last day Texas will administer the external review process. After that, any request for external review will be forwarded to one of the federal external review providers.

While insurers will take care of this transition for employer plan sponsors, those employers should be aware of this change in compliance.

Commissioner’s Bulletin # B-0001-18 »