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Commissioner’s Bulletin # B-0001-18

January 10, 2018


To: INSURANCE COMPANIES LICENSED TO WRITE HEALTH COVERAGE IN THE STATE OF TEXAS, HEALTH MAINTENANCE ORGANIZATIONS (HMOs), INDEPENDENT REVIEW ORGANIZATIONS (IROs), AND UTILIZATION REVIEW AGENTS (URAs) CONDUCTING UTILIZATION REVIEW FOR A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY


Re: TRANSITION TO FEDERAL EXTERNAL REVIEW PROCESS

This bulletin notifies health insurance issuers, HMOs, IROs, and URAs in Texas of an upcoming transition and related changes and deadlines for the external review processes for some health plans.

The federal government has adopted external review requirements under the Affordable Care Act (ACA) that are inconsistent with Texas law.  As such, the Texas Department of Insurance (TDI) cannot enforce some federal requirements for external review. Previously, temporary federal standards allowed issuers to follow the external review processes under Texas law. However, those temporary standards have ended. Because of this TDI and the Centers for Medicare and Medicaid Services (CMS) are working together to provide a smooth transfer from the Texas external review process to the federal external review process for issuers who must now comply with all the federal requirements.

As part of the transition, TDI will continue to process eligible requests for external review it receives through June 30, 2018. At the same time, issuers providing health insurance plans under the ACA will also be responsible for meeting the following CMS deadlines related to changing to a federal external appeals process.

  • February 16, 2018: Date by which issuers must inform CMS of which external review process they intend to use by electing either the HHS-administered process, which is currently managed by Maximus, or by contracting with three URAC-accredited IROs. Instructions for this election are available at the following link: www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/HHS-SRG-on-HIOS-elections_-FINAL.pdf.

  • March 31, 2018: Date by which issuers must submit any updated notice, policy or plan documents, and adverse benefit determination notices to CMS and TDI for review. The documents and notices should be submitted to CMS through the HIOS form filing module and to TDI through the SERFF form filing module.

  • June 30, 2018: Date by which issuers must send notices and updated policy or plan documents to enrollees.
June 30, 2018, is the last day Texas will administer the external review process for healthcare plans subject to the ACA external review requirements. Any external requests TDI receives after that date will be forwarded to either the issuer or plan or Maximus for processing, depending on which federal external review process the issuer or plan has elected to use.

CMS addressed the transition period for state external review processes in federal regulations at 45 CFR § 147.136(c)(3). A copy of the entire rule is available online in the Federal Register, Volume 80, No. 222 at the following link: www.federalregister.gov/documents/2015/11/18/2015-29294/final-rules-for-grandfathered-plans-preexisting-condition-exclusions-lifetime-and-annual-limits. Issuers, IROs, URAs, and plans may submit questions on the election process or the federal review process to ExternalAppeals@cms.hhs.gov.

The changes for external review processes addressed in this bulletin are not applicable to external review for plans not subject to ACA requirements or external review processes for care provided under workers’ compensation coverage, nor do they affect the department’s oversight of utilization review requirements or certification of IROs.

Questions regarding this bulletin should be directed via email to MCQA@tdi.texas.gov.


For more information, contact:

Last updated: 1/12/2018