A project of the George Washington University's Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation

IRS releases employer mandate draft forms

Posted on July 25, 2014 | No Public Comments

The Internal Revenue Services (IRS) released two draft forms for employers required to adhere to the employer shared responsibility payment, or employer mandate, under the Affordable Care Act (ACA).  Beginning in 2015, employers with 100 or more employees will be required to provide health insurance to their employees pursuant to the ACA, and employers with more than 50 employees will be expected to comply with the mandate beginning in 2016.  The new draft forms are currently available for comment.

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10.3 million adults estimated to have gained coverage under the ACA

Posted on July 24, 2014 | No Public Comments

A new study published in the New England Journal of Medicine found that an estimated 10.3 million adults gained insurance coverage under the Affordable Care Act (ACA).  The study, performed by Harvard researchers, reported a 5.2% decline in the uninsured rate during the first open enrollment period.  Data analyzed for this project included Gallup polls and ACA enrollment statistics from the US Department of Health and Human Services (HHS).

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HRSA removes orphan drug exemption under 340B

Posted on July 22, 2014 | No Public Comments

A rule released yesterday by the Health Resources and Services Administration (HRSA) clarifies a portion of the 340B program, which requires drug manufacturers to offer their pharmaceuticals at a discounted rate to covered entities.  Under 340B, a covered entity typically refers to healthcare providers treating medically vulnerable populations, such as Ryan White Clinics or Disproportionate Share Hospitals.  The new rule specifically removes the discount exemption for orphan drugs sold for off-label usage.  A recent lawsuit led to the promulgation of this interpretative rule,  as many orphan drugs are used to treat conditions other than the rare conditions for which the drugs were created.

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Courts issue conflicting ACA decisions

Posted on July 22, 2014 | No Public Comments

Today, two federal appeals courts issued contradictory decisions regarding the availability of advanced premium tax credits, or subsidies, for federally-facilitated marketplaces (FFM).  In a 2-1 decision in Halbig v. Burwell, the US Court of Appeals for the DC Circuit ruled that the Internal Revenue Services (IRS) did not possess the authority to issue subsidies for qualifying individuals enrolling in FFM.  In a similar case entitled King v. Burwell, the Fourth Circuit Court of Appeals in Richmond unanimously upheld that subsidies may be offered by the IRS in both federally-facilitated and state-based Marketplaces.  Under the Affordable Care Act (ACA), individuals earning 400% or less of the federal poverty level may receive subsidies in order to offset some of the premium costs for obtaining health insurance through the ACA Marketplaces.  The differing opinions issued today indicate that this issue will likely be taken up by the Supreme Court.

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CMS releases 2015 Medicare payment rules

Posted on July 4, 2014 | No Public Comments

The Centers for Medicare and Medicaid Services (CMS) issued several rules concerning Medicare payments for 2015.  First, CMS released the 2015 physician fee schedule.  Pursuant to the “doc fix” legislation recently passed, this proposal holds physician payments for the first quarter of next year.  The rule also bolsters the Physician Payment Sunshine Act by requiring providers to report payments received from speaking at continuous education events.  Additionally, the proposal revises the quality scoring methodology so that accountable care organizations (ACOs) are better able to exemplify the improvements they make in quality measures.  The number of metrics will increase from 33 to 37.

Yesterday, CMS also updated the payment scheme for outpatient services by 2.1% for 2015.  Biologics and non-pass-through drugs are still expected to be paid at average sales price plus 6%.  Payments are anticipated to increase by $5.2 billion compared to 2014.

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IG reports examine ACA enrollment applications

Posted on July 1, 2014 | No Public Comments

The US Department of Health and Human Services Office of the Inspector General (OIG) released two new reports concerning enrollment into qualified health plans (QHP) under the Affordable Care Act (ACA). The first report found that the vast majority of application inconsistencies were not resolved within the first three months of the open enrollment period. According to the report, many of the inconsistencies dealt with reported income and citizenship status, and states are at various points in rectifying these application data inconsistencies.

Another report investigated whether or not federally-facilitated Marketplaces (FFM) and two state-based Marketplaces (SBM) were able to verify enrollment eligibility. During the same three month window, OIG found that the FFM was not able to verify social security numbers. For the SBM states, California and Connecticut, the report found that both states also had some ineffective controls in regards to confirming various aspects of QHP enrollment.

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CMS releases proposed rule on annual eligibility determinations

Posted on June 26, 2014 | No Public Comments

A new proposed rule issued today by the Center for Consumer Information and Insurance Oversight (CCIIO) discussed annual eligibility redetermination under the Affordable Care Act (ACA) and several other enrollment standards for ACA Marketplace. CCIIO stated that nearly all of those currently enrolled in an ACA Marketplace plan will be re-enrolled unless they choose a new plan in the next open enrollment period or the plan in which they are currently enrolled is terminated. The rule proposes three methods for ACA Marketplaces to conduct annual redeterminations for enrollment. The rule also proposes standards to redetermine eligibility within a plan year and when an individual’s plan in the ACA Marketplace is not available for re-enrollment for the next plan year.

Additional guidance includes:

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Two new ACA studies released

Posted on June 26, 2014 | No Public Comments

A new study published in Health Affairs found that open enrollment for the Affordable Care Act (ACA) should coincide with the tax filing season. The researchers argued that consumers are more likely to make better decisions with their health coverage when taxes are on their minds, not the stresses associated with holiday spending. Currently, ACA open enrollment for 2015 is scheduled for November 15, 2014 to February 15, 2015.

Another study from the Urban Institute indicates that Medicaid expansion was associated with a reduction in the number of uninsured individuals as of March 2014. The study, which relied upon data from Urban’s Health Reform Monitoring Survey, found that states expanding Medicaid saw a drop in the uninsurance rate by 4%, whereas states that did not expand Medicaid saw a 1.4% reduction. Unlike the ACA open enrollment period, individuals eligible for Medicaid can enroll in the program at any point in a year.

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Rule finalizes 90-day waiting limit

Posted on June 20, 2014 | No Public Comments

Today, the US Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA) released a final rule concerning the 90-day waiting period limitation. The final rule states that group health insurance plans cannot apply a waiting period that exceeds 90 days after the employee has been approved for coverage. The rule further states that small group plan orientation periods, the time it takes from hire to when the plan deems the employee is eligible for coverage, cannot exceed one month.

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New brief discusses premium rate review

Posted on June 20, 2014 | No Public Comments

The Robert Wood Johnson Foundation and the Leonard Davis Institute of Health Economics at Penn released a brief on premium proposals and rate review under the Affordable Care Act (ACA). The brief, Deciphering the Data: Health Insurance Rates and Rate Review, discusses the economic, political, and regulatory factors that contribute to rate determinations. Additionaly, the brief discusses how states with prior approval for rate review authority increased their capacity and scope to coincide with requirements under the ACA.

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