Fact Sheet

U. S. Department of Labor
November 20, 2000

Patients’ Rights Claims Procedure Regulation


In the years since 1977, when the Department first adopted a benefit claims regulation under ERISA, the health care industry has seen dramatic changes. Those changes have shifted the usual method of delivery of health care from doctors making independent medical decisions, while indemnity insurance companies decide later whether to pay, to integrated delivery systems under which “managed care” organizations review and oversee doctors’ medical decisions, often before care is provided.

The patients’ rights claims procedure regulation, which is now being issued in final form, creates new important patient protections that will ensure that group health plan participants in today’s managed care environment have access to a faster, fairer, fuller process for benefit determinations.

Faster Decisions

Faster decisions on initial claims - rather than 90 days (or more) under current regulation, the new rule would require decisions (in most cases) not later than:

Faster decisions on appeal of denied claims - rather than 60 days (or more) under current regulation, the new rule would require decisions (in most cases) not later than:

Fairer Process

Fuller Disclosure

Final Rule on Summary Plan Description

-- Provides that health plan SPDs must describe:

- Requires that the SPDs of pension and welfare benefit plan describe, among other things, the procedures on qualified domestic relation orders (QDROs) and qualified medical child support orders (QMCSCOs), the plan sponsor’s authority to terminate the plan or eliminate benefits under the plan, COBRA continuation rights, and updated information on coverage by the Pension Benefit Guaranty Corporation and ERISA rights.

- Repeals the limited exemption relating to SPDs of health plans that provide benefits through qualified health maintenance organizations (HMOs). Thus, health plans that provide benefits through a federally qualified HMO must comply with the improved SPD disclosure rule.
SEE: 29 CFR 2560.503-1

Consumer Information Card: What you should know about filing your health benefits claim