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HHS Happenings: Agency Offers Waiver Resources, Online Portal


Recently, the Department of Health and Human Services (HHS) released guidance on a couple of topics related to health care benefits that may be of interest to certain employers. The guidance involves state innovation waivers and the federally required external review process for some group health plans. Here are the details.

Innovation waiver resources

The Centers for Medicare and Medicaid Services (CMS) released resources to support states seeking Affordable Care Act (ACA) innovation waivers. The ACA authorizes states to apply for waivers from certain of its provisions, including requirements regarding:

  • Qualified health plans
  • Health Care Marketplaces (commonly known as “exchanges”)
  • Premium tax credits
  • Employer shared responsibility

To obtain a waiver, a state must provide coverage that’s at least as comprehensive and affordable as would be provided absent the waiver. Also, the number of state residents with coverage must be comparable to the number of residents who would have coverage absent the waiver. In addition, an innovation cannot increase the federal deficit.

The HHS website has been updated with new resources designed to help states better understand and navigate the waiver application process, including a checklist of required waiver elements and model templates aligned with previously released “waiver concepts.” These resources underscore agency efforts to increase flexibility for states to obtain waivers from the ACA’s requirements.

Online portal for external review process

The HHS has updated its technical guidance setting forth requirements for group health plans and insurers using the HHS-administered federal external review process.

For specified types of adverse benefit determinations, group health plans must make available an external review process meeting certain standards, either pursuant to a state process (generally applicable to insurers and self-insured plans not subject to ERISA) or a federal process (for self-insured ERISA plans). Insured plans not subject to an applicable state external review process and self-insured nonfederal governmental plans may elect to use a federal external review process pursuant to applicable regulations or the HHS-administered federal external review process outlined in this guidance. This update replaces previous versions.

The updated guidance announces that MAXIMUS, the federal contractor that administers this process on behalf of the HHS, now offers an online portal for requesting an external review. It also advises that notices of adverse benefit determination and final internal adverse benefit determination will need to be updated to note this new feature. The notices must:

  • Provide the Web address for the portal
  • Explain how to submit the request online
  • Include information about submitting external review requests by mail or fax
  • State that expedited review may be requested via the online portal or by phone or email

The guidance specifies the relevant Web address, street address, phone and fax numbers, and email address. Plans and insurers must electronically submit samples of their updated notices to the HHS. In other respects, the external review procedures described in this guidance remain generally unchanged from prior versions. Nonetheless, plans and insurers using the HHS-administered federal external review process should act quickly to update their notices and submit them to the HHS, as it appears that the online portal is already in use.

Important updates

The HHS guidance on both above topics represents important updates to these subject areas. If you believe they affect your organization, discuss the impact with your benefits advisors.



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