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Phia Group Media

Keeping PACE With COVID-19 Developments

By: David Ostrowsky

On January 30, 2023, the Biden administration announced its plan to terminate the national emergency and public health emergency declarations pertaining to the COVID-19 pandemic. Effective May 11, 2023, the phasing out of the public health emergency will mean a change in coverage requirements (i.e., vaccines administered out-of-network can involve cost sharing, no longer will there be free at-home COVID tests), while the end of the national emergency will affect the tolling of various health benefits related deadlines. The latter issue is one that resonates particularly strongly with The Phia Group’s PACE (“Plan Appointed Claim Evaluator”) service, whereby Phia manages final internal appeals, defends its decisions in the face of external appeal, and oversees the Independent Review Organization (“IRO”) external appeal process.

A quick summary of the COVID-19 national emergency period and its imminent ending:

In the early stages of the pandemic, benefit plans were required to toll plan deadlines during the period from March 1, 2020, until 60 days after the end of the COVID-19 National Emergency (which would be July 10, 2023). What did this mean? For the past three years, plan participants (and their beneficiaries) were provided with extra time to file benefit claims and appeals; elect and pay for COBRA coverage as well as comply with COBRA notice obligations; and request special enrollment in a health plan. But now, this July 10, tolling will finally cease, and pre-COVID plan deadlines will once again be in effect.

For example, if an employee’s obligation to file claims with the TPA within 180 days of incurred charges started on August 1, 2022, the claim filing period will no longer be extended as of July 10, 2023. But there’s an important caveat to this discussion. Once the pandemic lingered longer than expected, it was announced that, irrespective of the aforementioned tolling provision, the maximum tolling period for any person would be one year. Thus, if that employee’s responsibility to file claims within 180 days began on July 1, 2022, tolling would end on July 1, 2023, due to the maximum one-year tolling stipulation.

The bottom line is that in either case, timelines for filing claims and appeals, requesting external reviews, COBRA elections, and HIPAA special enrollment will revert back to their pre-2020 status.

Of course, for plan administrators and sponsors, it’s not simply a matter of dusting off the 2019 plan documents and reinstating them. There’s quite a few matters to consider—whether it be plan language modifications or updates to claim systems—to ensure proper compliance with the evolving regulations. And as always, PACE is available to not only provide legal and analytical expertise but also to serve as your fiduciary in handling final level appeals.