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Benefits

How Long Are the Extended Claims and Appeals Time Periods During the COVID-19 Emergency?

EBIA  

EBIA  

QUESTION: We understand that we are required to extend the time periods applicable to claims and appeals under our group health plan due to the COVID-19 emergency. How long is the extension?

ANSWER: In response to the COVID-19 emergency, federal agencies have extended certain claims and appeals time periods for group health plans (as well as disability and other employee welfare benefit plans, and employee pension benefit plans) that are subject to ERISA or the Code (see our Checkpoint article). The extension permits the “outbreak period”—beginning March 1, 2020, and ending 60 days after the announced end of the COVID-19 emergency—to be disregarded for specified purposes related to claims.

Affected timeframes include the deadlines for individuals to notify the plan of a qualifying event or determination of disability, to file claims for benefits, and to file appeals of adverse benefit determinations under ERISA plans and non-grandfathered group health plans. And deadlines have been extended for requesting external review following exhaustion of the plan’s internal appeals procedures. Other deadlines that apply for perfecting an incomplete request for review are also extended.

For example, if the COVID-19 national emergency had ended on April 30, 2020, the disregarded outbreak period would have ended 60 days later, on June 29. Thus, if an employee received medical treatment on March 1, 2020, but did not submit a claim relating to the medical treatment until April 1, 2021, and the plan required that claims be submitted within 365 days of the receipt of the medical treatment, this participant’s request would be considered timely submitted. To determine the 365-day period applicable to the claim, the outbreak period is disregarded. Therefore, the last day to submit a claim is 365 days after June 29, 2020, which is June 29, 2021.

Also, based on the same assumptions, if an individual received a notification of an adverse benefit determination from his disability plan on January 28, 2020, which notified him that there were 180 days within which to file an appeal, the employee’s appeal deadline would be determined by disregarding the outbreak period. Therefore, the last day to submit the appeal would be 148 days (180 less 32 days elapsed from January 28 to March 1) after June 29, 2020, which would be November 24, 2020.

Although plans are not expressly granted more time to process and decide claims, the DOL recognizes that the COVID-19 emergency may present challenges for plans in achieving “full and timely compliance” with ERISA’s claims procedure requirements, and has said that its approach to enforcement will emphasize compliance assistance and may include other relief.

For more information, see EBIA’s ERISA Compliance manual at Sections XXXIV.F (“Timelines Under Group Health Plan Procedures”), XXXIV.M (“External Review Requirements”), and XXXV.E (“Timelines for Disability and Other Non-Health Decisions”). See also EBIA’s Health Care Reform manual at Section XV (“Appeals Process and External Review Requirements”) and EBIA’s Self-Insured Health Plans manual at Section XXVI.E (“Timelines Under Group Health Claims Procedures”).

Contributing Editors: EBIA Staff.

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