Keenan Briefings

Briefings

Guidance Issued on HIPAA Special Enrollment Rights, Claims Procedures and External Review Timeframes

May 12, 2020

On May 4, 2020, the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) and the Internal Revenue Service (IRS) issued regulatory guidance extending certain timeframes under the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code for group health plans, disability and other welfare plans, pension plans and participants and beneficiaries of these plans during the COVID-19 national emergency. These changes were made both to minimize the possibility of individuals losing benefits because of a failure to comply with statutory and regulatory timeframes and in recognition that affected group health plans may have difficulty during this time in complying with certain notice obligations.

The regulations impact timelines for COBRA, HIPAA special enrollment rights, claims procedures and external review processes and can affect group and individual health, disability and pension plans. This Briefing will discuss the changes that affect HIPAA special enrollment rights, claims procedures and external review processes.We have issued a separate Briefing that summarizes the changes that impact COBRA timelines.

The guidance establishes a period of time from March 1, 2020 until 60 days after the announced end of the COVID-19 national emergency (or such other date announced by EBSA and the IRS in future guidance) as the “Outbreak Period.” Plans must disregard the Outbreak Period for purposes of the timeframes discussed below.

HIPAA Special Enrollment Rights

Group health plans must disregard the Outbreak Period for purposes of:

  • The 30-day period to request a special enrollment in a group health plan; and
  • The 60-day period to request enrollment into a group health plan upon losing eligibility for CHIP coverage becoming eligible for the CHIP subsidy.

Example: The regulations cite the following example, assuming that the national emergency ends on April 30, 2020, with the Outbreak Period ending on June 29, 2020 (the 60th day after the end of the national emergency). Individual B is eligible for, but previously declined participation in, her employer-sponsored group health plan.On March 31, 2020, Individual B gave birth and would like to enroll herself and the child into her employer’s plan (for which open enrollment does not begin until November 15). In this case, Individual B may exercise her special enrollment rights for herself and her child into her employer’s plan until 30 days after June 29, 2020 (which is July 29, 2020) provided that she pays the premiums for any period of coverage.

Claims Procedure Timeframes

Individual and group health, disability and pension plans must disregard the Outbreak Period for purposes of:

  • The date within which individuals may file a benefit claim under a plan’s claims procedures; and
  • The date within which a claimant may file an appeal of an adverse benefit determination under a plan’s claims procedures.

Example: The regulations cite the following example, assuming that the national emergency ends on April 30, 2020, with the Outbreak Period ending on June 29, 2020 (the 60th day after the end of the national emergency). Individual D is a participant in a group health plan.On March 1, 2020, Individual D received medical treatment for a condition covered under the plan, but a claim relating to the medical treatment was not submitted until April 1, 2021. Under the plan, claims must be submitted within 365 days of the participant’s receipt of the medical treatment. Individual D’s claim is timely. For purposes of determining the 365-day period applicable to Individual D’s claim, the Outbreak Period is disregarded. Therefore, Individual D’s last day to submit a claim is 365 days after June 20, 2020, which is June 29, 2021.

External Review Process Timeframes

Individual and group health plans must disregard the Outbreak Period for purposes of:

  • The date within which a claimant may file a request for an external review after receipt of an adverse benefit determination or final internal adverse benefit determination.
  • The date within which a claimant may file information to perfect a request for external review upon a finding that the request was not complete.

Example: The regulations cite the following example, assuming that the national Emergency ends on April 30, 2020, with the Outbreak Period ending on June 29, 2020 (the 60th day after the end of the national emergency). Individual F received a notice of adverse benefits determination from Individual F’s 401(k) plan on April 15, 2020. The notification advised Individual F that there are 60 days within which to file an appeal. When determining the 60-day period within which Individual F’s appeal must be filed, the Outbreak Period is disregarded. Therefore, Individual F’s last day to submit an appeal is 60 days after June 29, 2020, which is August 28, 2020.

The full regulatory guidance can be found at the link below:

https://www.federalregister.gov/documents/2020/05/04/2020-09399/extension-of-certain-timeframes-for-employee-benefit-plans-participants-and-beneficiaries-affected

While these changes will be welcomed by plan participants, they will certainly create additional complexity in administering the affected benefit plans.If you have any questions regarding the regulatory action or its impact on your benefit plan, please contact your Keenan Account Manager.


Keenan & Associates is not a law firm and no opinion, suggestion, or recommendation of the firm or its employees shall constitute legal advice. Clients are advised to consult with their own attorney for a determination of their legal rights, responsibilities and liabilities, including the interpretation of any statute or regulation, or its application to the clients’ business activities.