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Behind the Curtain: The Affordable Care Act’s Impact on Small Business

Behind the Curtain: The Affordable Care Act’s Impact on Small Business. What’s Behind the Interim Final Rules? Presented By: Thomas M. Christina (Greenville). Interim Final Rules Relating to Internal Claims and Appeals Processes. Pre-Act Standard: “Full and Fair Review”

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Behind the Curtain: The Affordable Care Act’s Impact on Small Business

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  1. Behind the Curtain: The Affordable Care Act’s Impact on Small Business What’s Behind the Interim Final Rules? Presented By: Thomas M. Christina (Greenville)

  2. Interim Final Rules Relating toInternal Claims and Appeals Processes • Pre-Act Standard: “Full and Fair Review” • IFR: “[T]he plan and issuer must ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. . . .

  3. Treas. Reg. § 54.9815-2719T(b)(2)(D) • ““[T]he plan and issuer must ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. Accordingly, decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) must not be made based upon the likelihood that the individual will support the denial of benefits.”

  4. Grandfathered Plans • Section 1251 • Purpose: Preserving the ability to stay with satisfactory pre-Act plans

  5. From the Preamble to Interim Final Rules on Grandfathered Health Plan Status • “Even when an enrollee could reap an economic or other advantage from changing plans, that enrollee may not make the change because of inertia, a lack of relevant information, or because of the cost and effort involved in examining new options and uncertainty about the alternatives."

  6. From the Preamble With Emphasis • “Even when an enrollee could reap an economic or other advantage from changing plans, that enrollee may not make the change because of inertia, a lack of relevant information, or because of the cost and effort involved in examining new options and uncertainty about the alternatives.”

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