Among numerous changes to the Medicare and Medicaid Program Integrity Provisions, Section 6402 the Patient Protection and Affordable Care Act (“PPACA”) contains urgent requirements for reporting and returning overpayments. The new provision requires certain entities – including providers, suppliers, …
Comments on Adult Child Coverage
August 11, 2010 Leave a Comment
We continue to receive questions from our clients about the scope of coverage for adult children. Although the tax guidance defined child as any natural, adopted, step or foster child, the coverage guidance did not define the term. The issue is whether dependency or residency conditions are allowed for …
New Statute Sheds Light on Three-Day Rule for Hospital Billing
August 6, 2010 Leave a Comment
On June 25, 2010, President Barack Obama signed into law the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010. Among other provisions, Section 102 of the legislation broadens the interpretation of what is known as the three-day rule, Medicare's policy for payment for …
New Rules: Internal Claims and Appeals and External Review Process
July 27, 2010 Leave a Comment
The government published rules on July 23 implementing new internal claims and appeals and external review processes under health care reform. The rules, effective for plan or policy years beginning on or after September 23, address new requirements for state external review processes that apply mainly to fully …
When are annual and lifetime limits allowed?
July 17, 2010 1 Comment
Recent regulations confirm that the general prohibition on annual and lifetime limits applies only to "essential health benefits." That is, annual and lifetime limits are permissible for "non-essential" health benefits. In addition, for plan years beginning before January 1, 2014, group health plans may establish …
What is an “essential health benefit”?
July 15, 2010 Leave a Comment
The health care reform statute provides that "essential health benefits" must be defined to include the following categories of services: Ambulatory patient services; Emergency services; Hospitalization; Maternity and newborn care; Mental health and substance use disorder services, including behavioral …