When a patient’s claim gets declined due to non-coverage, the patient may tell you they’re taking advantage of longer enrollment grace periods that have been in place due to the public health emergency (PHE) and refuse to pay out of pocket. But as the PHE approaches its May 11 ending date, it’s a good idea to evaluate the ERISA health insurance changes and how they’ll impact your patients’ coverage, since they may have less time to enroll than they think.
Check out a few examples that can guide your ERISA health insurance deadline know-how in light of the upcoming end to the PHE.
How the PHE Impacted ERISA
To get a handle on how the public health emergency impacted ERISA and medical coverage, it’s important to get a bit of background. In essence, the law says that people have a certain time limit for enrolling in COBRA coverage after leaving their jobs, and they also have a specific timeframe during which they must file claims, appeals and requests for external reviews.
During the pandemic, those deadlines were adjusted under the rules governing the COVID-19 Outbreak Period, which is slightly different from the actual PHE—however the two have an important connection. The Outbreak Period lasts from March 1, 2020 through the earlier of:
- One year after the date a person is initially eligible for ERISA deadline extensions OR
- 60 days after the PHE ends
This means that any extensions patients had to elect coverage or appeal coverage denials are likely to end by mid-July, since that will mark 60 days after the PHE expires, thus halting the Outbreak Period. At that point, any deadline extensions patients had to elect coverage or appeal denials under their employee-sponsored insurance plans will go back to the timeframes patients had to follow prior to the pandemic. These may differ from one patient to the next depending on their plan specifics, so there will be no set deadline when every patient is out of options and should be considered self-pay. That’s why it’s important to tighten up your insurance pre-authorization program before patients present for appointments so you’ll know who is still eligible for insurance appeals, who has been dropped from their insurers, and who is still within the time period to apply for employer-sponsored insurance.
Example: Patients Awaiting COBRA Coverage
To get a feel for how this may impact your practice, check out these examples.
First, let’s say a patient’s original deadline to elect COBRA continuation coverage was March 1, 2022. The pandemic delayed that deadline until the earlier of one year from that date (e.g., March 1, 2023) OR the end of the Outbreak Period (July 11, 2023). So that patient only has until March 1, 2023 to elect COBRA coverage, since that’s the earlier date. After that date, the patient is not likely to be accepted onto the COBRA plan.
For a second example, suppose the patient’s original COBRA election deadline was August 1, 2022. The pandemic delayed that deadline until the earlier of one year from that date (e.g., August 1, 2023) OR the end of the Outbreak Period (July 11, 2023). Therefore, that patient has until July 11, 2023 to elect COBRA coverage, since that’s the earlier date. After that date, the patient is unlikely to be accepted by the COBRA plan.
Caveat: Plan administrators have legal requirements they must meet before dropping patients from insurance plans or withdrawing their enrollment options. For instance, they must provide notices by certain dates if a patient is about to lose coverage. Plan administrators who don’t meet these requirements—or who choose to extend deadlines—can lead to patients not having to adhere to the dates laid out above. That’s why it’s imperative to pre-authorize every patient and ensure that your practice’s legal counsel is involved before you roll out any changes related to the ERISA deadlines that are impacted by the PHE.
PHE Also Impacts Patients Appealing Coverage
You’ll also find that the end of the Outbreak Period and PHE will impact the amount of time patients have to appeal claims, ask for requests for external reviews, and notify the plan of a qualifying event or disability determination. In addition, the government plans to launch a special enrollment period so patients can apply for Affordable Care Act coverage outside of the normal health insurance enrollment period.
Because all of these changes have their own deadlines and rules around them, it’s essential for your practice to consult with a qualified healthcare attorney who’s well-versed in ERISA laws to ensure you are handling patient coverage appropriately.
Find out more about the complex ERISA rules by participating in the online training session, “Keep More of Your Reimbursement: Make ERISA Work for You.” During this 90-minute training,
David J. Zetter, PHR, SHRM-CP, CHC, CPCO, CPC, COC, PCS, FCS, CHBC, CMUP, PESC, CMAP, CMAPA, CMMP, CMHP, will provide you with the steps every practice must take to master the ERISA laws. Sign up today!
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