Patient Protection and Affordable Care Act (PPACA) retroactive termination policies are in effect
We are writing with an important notice about the retroactive termination policy that applies to all fully-insured customers. AmeriHealth New Jersey wants to ensure that you, your staff, and your customers understand the importance of compliance with this policy as part of health care reform. If you have not discussed this with your staff and customers already, now is the time to take action to help avoid potential financial penalties to your customers.
The retroactive termination policies
Per the PPACA retroactive termination guidelines, the period of time in which AmeriHealth New Jersey will retroactively terminate members for fully-insured groups has changed from 60 days plus the current month to 30 days plus the current month in which the request was made. The PPACA prohibits health insurers and group administrators from rescinding coverage except in the case of fraud, intentional misrepresentation of material facts, or failure to pay required premiums. A rescission is defined as a cancellation of coverage that has a retroactive (occurring in the past) termination date.
Please note that when requests for retroactive terminations are submitted, AmeriHealth New Jersey will regard the submission as certification that the termination is in the normal course of business and certification that no premium/contribution was paid by the member/dependent for that period. If a member paid premium or contributed to the cost of the plan, coverage may not be terminated with a past effective date except in the case of fraud or a misrepresentation of a material fact. The group health plan or health insurance issuer must provide a 30 day written notice of coverage termination to each individual affected by the termination before coverage may be rescinded. The member has the right to appeal the rescission of coverage.
To comply with the PPACA, the AmeriHealth New Jersey retroactive termination policy for fully-insured customers is as follows:
- For fully-insured groups, retroactive terminations may be made for up to 30 days plus the current month (30-60 days). This means that a termination cannot be made for more than 60 days before the date that AmeriHealth New Jersey is notified.
The policy for self-funded groups remains unchanged:
- For self-funded groups, retroactive terminations may be made for up to 60 days plus the current month (60-90 days). This means that a termination cannot be made for more than 90 days before the date that AmeriHealth New Jersey is notified. Self-funded groups can decide how to implement retroactive terminations within this timeframe.
Help your customers avoid potential penalties for non-compliance
If you have not discussed the impact of the PPACA retroactive termination guidelines with your staff and customers we urge you to do so now. By doing this you will help to ensure that retroactive termination requests are processed in accordance with PPACA specifications.
To help your groups to avoid potential penalties, when a termination date is requested that is outside the guidelines above, a letter will be sent to the group administrator that will advise that the termination date has been adjusted to fall within the policy guidelines.
Please be assured that AmeriHealth New Jersey complies with the applicable provisions of the PPACA. Our goal is the same as yours; to provide our customers with quality benefits at the best possible price. We greatly appreciate your efforts to support these initiatives. If you have any questions, please contact your AmeriHealth New Jersey broker representative.