Reform Alert - News from the Blues' Office of National Health Reform

Health and Human Services releases interim final rule about application requirements for early retiree reinsurance

149.40 Application

The applicant must submit an application to participate in this program to the Secretary, which is signed by an authorized representative of the applicant who certifies that the information contained in the application is true and accurate to the best of the authorized representative's knowledge and belief.

Applications will be processed in the order in which they are received.

An application that fails to meet all the requirements of this part will be denied and the applicant must submit another application if it wishes to participate in the program. The new application will be processed based on when the new submission is received.

An applicant need not submit a separate application for each plan year but must identify in its application the plan year start and end date cycle (starting month and day, and ending month and day) for which it is applying.

An applicant must submit an application for each plan for which it will submit a reimbursement request.

1.  Applicant's Tax Identification Number. 

2.  Applicant's name and address. 

3.  Contact name, telephone number and email address. 

4.  Plan sponsor agreement signed by an authorized representative, which includes - 

i.  An assurance that the sponsor has a written agreement with its health insurance issuer (as defined in 45 CFR 160.103) or employment-based plan, as applicable, regarding disclosure of information to the Secretary, and the health insurance issuer or employment-based plan must disclose to the Secretary, on behalf of the sponsor, at a time and in a manner specified by the Secretary in guidance, information, data, documents, and records necessary for the sponsor to comply with the requirements of the program. 

ii.  An acknowledgment that the information in the application is being provided to obtain federal funds, and that all subcontractors acknowledge that information provided in connection with a subcontract is used for purposes of obtaining federal funds. 

iii.  An attestation that policies and procedures are in place to detect and reduce fraud, waste, and abuse, and that the sponsor will produce the policies and procedures, and necessary information, records and data, upon request by the Secretary, to substantiate existence of the policies and procedures and their effectiveness. 

iv.  Other terms and conditions required by the Secretary. 

5.  A summary indicating how the applicant will use any reimbursement received under the program to meet the requirements of the program, including: 

i.  How the reimbursement will be used to reduce premium contributions, co-payments, deductibles, coinsurance, or other out-of-pocket costs for plan participants, to reduce health benefit or health benefit premium costs for the sponsor, or to reduce any combination of these costs; 

ii.  What procedures or programs the sponsor has in place that have generated or have the potential to generate cost savings with respect to plan participants with chronic and high-cost conditions; and 

iii.  How the sponsor will use the reimbursement to maintain its level of contribution to the applicable plan. 

6.  Projected amount of reimbursement to be received under the program for the first two plan year cycles with specific amounts for each of the two cycles. 

7.  A list of all benefit options under the employment-based plan that any early retiree for whom the sponsor receives program reimbursement may be claimed. 

8.  Any other information the Secretary requires. 

9.  An application must be approved, and the plan and the sponsor certified, by the Secretary before a sponsor may request reimbursement under the program. 

10.  The Secretary may reopen a determination under which an application had been approved or denied: 

i.  Within one year of the determination for any reason; 

ii.  Within four years of the determination if the evidence that was considered in making the determination shows on its face that an error was made; or 

iii.  At any time in instances of fraud or similar fault.

The information on this website is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.