What is happening?
As of July 1, 2011, benefit book information will be included in EOBs for members on non-grandfathered plans to help explain adverse determination codes.
How is “Adverse Determination” defined?
An adverse claim determination is defined as “any instance where a plan pays less than the total amount of expenses submitted with regard to a claim, including a denial of part of the claim due to the terms of a health plan or health insurance coverage regarding copayments, deductibles, or other cost-sharing requirements.”
Who does this impact?
This change impacts non-grandfathered group members who are new or have plan renewals after July 1, 2011 and have an adverse determination on their EOB.
When are the changes effective?
EOB changes are based on renewal as of July 1, 2011. This change only impacts non-grandfathered groups.
Why are the changes being made?
The new requirements are the result of specific provisions in Healthcare Reform. Many regulations set forth in the Affordable Care Act protect consumers and help patients be more in charge of their care. To better support the consumer protections of healthcare reform, there are new rules that expand on consumers’ rights to appeal decisions, including claims denials and rescissions, made by their health plans.
What does this mean?
- As of July 2011, members with non-grandfathered plans may begin receiving a revised EOB, based on requirements included in federal healthcare reform.
- The change will apply to individual non-grandfathered plans and new or renewing groups with non-grandfathered plans as of July 1, 2011.
- The EOB will now include:
-contract language taken from the member’s benefit booklet about their plan’s coverage; and
-a description of the availability of and contact information for state or federal consumer assistance or ombudsmen program.
How will members learn about this change?
- Members will notice minor changes on the revised EOB. When applicable, information from the members benefit booklet will be included.
- When a claim has an “adverse determination,” we will provide actual benefit booklet language that corresponds with denial codes related to the claim determination.
- For more information about their health plan’s coverage, members of some groups can obtain a copy of their benefit booklet by logging in to lifewiseor.com.
