Centers for Medicare & Medicaid Services

Update to Consumer Operated and Oriented Plan (CO-OP) Program: Final Rule

Posted on January 18, 2012

The Centers for Medicare and Medicaid Services (CMS) issued its final rule implementing the Consumer Operated and Oriented Plan (CO-OP) Program on December 13, 2011. This rule finalizes the notice of proposed rulemaking (NPRM) issued by CMS on July 20, 2011, and takes into consideration the numerous comments received during the public notice and comment period ending September 16, 2011. Established by §1322 of the Affordable Care Act (ACA), the CO-OP program develops and creates new private, non-profit health insurance issuers to offer qualified health plans (QHPs) through state Exchanges as an alternative for consumers to traditional, for-profit plans. CO-OP plans are consumer-run, and accountable to their individual membership in a way that most traditional for-profit health plans typically are not. The ACA requires HHS to award funds for start-up loans and solvency grants to eligible CO-OP applicants in order to enable each state to have at least one CO-OP. In making these awards, HHS must take into account recommendations from the Advisory Board created by ACA §1322(b)(2). Two previous Implementation Briefs provided an overview of the CO-OP program and set forth the key provisions of the proposed rule; this update describes significant changes to the proposed rule as codified in the final rule.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Insurance, Implementation Briefs, Implementation Update, Rulemaking, Rules, and Guidance

HHS releases Medicaid quality measures

Posted on January 6, 2012

The Department of Health and Human Services (HHS) December 31, 2011 released a set of 26 quality measures to help track and improve health care delivered to Medicaid enrollees. The 26 quality measures are grouped into six major categories: 1) prevention and health promotion (e.g., flu shots for adults); 2) management of acute conditions (e.g., follow-up after hospitalization); 3) management of chronic conditions (e.g., controlling high blood pressure); 4) family experiences of care (e.g., surveys); 5) care coordination (e.g., timely transmission of records among providers); and 6) availability of care (e.g., prenatal and postpartum care). The development of these quality measures is mandated under the Affordable Care Act (ACA). Initially, HHS released a set of 51 proposed measures on December 31, 2010 and accepted public comments for two months. HHS reportedly received about 100 comments, many of which pertained to the overwhelming volume of quality measures. The Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare & Medicaid Services (CMS), and other agencies within HHS were involved in pairing down the final core set to 26 quality measures.

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Categories: Agency for Healthcare Research & Quality, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Key Developments, Medicaid and CHIP

Update: Essential Health Benefits

Posted on December 20, 2011

On December 16, 2011, the HHS Center for Consumer Information and Insurance Oversight (CCIIO) released an Essential Health Benefits Bulletin, whose purpose is to “provide information and solicit comments on the regulatory approach that the Department of Health and Human Services (HHS) plans to propose to define essential health benefits under section 1302 of the Affordable Care Act.” Comments on the Bulletin can be sent directly to EssentialHealthBenefits@cms.hhs.gov and will be accepted until January 31, 2011

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Insurance, Implementation Briefs, Implementation Update, Key Developments, Rulemaking, Rules, and Guidance

ACA Demonstration to provide home care for Medicare patients

Posted on December 20, 2011

The Centers for Medicare & Medicaid Services (CMS) announced today a new Demonstration under the Affordable Care Act (ACA) that will enable up to 10,000 Medicare beneficiaries with chronic conditions to receive most of their necessary care at home. The new Independence at Home Demonstration, a provision of the ACA, significantly expands the scope of in-home care that Medicare patients are eligible to receive. If they choose to opt into the Demonstration, beneficiaries with have access to a wide range of primary care services. Participation is optional. The Demonstration will reward providers with an incentive payment if they offer high-quality care care and reduce Medicare expenditures. CMS will implement quality measures to ensure beneficiaries experience high quality care under the new Demonstration.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Key Developments, Medicare

HHS announces 32 health care organizations to participate in Pioneer ACO Model

Posted on December 19, 2011

Today, the U.S. Department of Health and Human Service (HHS) named 32 health care organizations that will participate in the Pioneer Accountable Care Organization Model. The goal of the new ACO Model is to encourage providers, hospitals, specialists, and caregivers to provide more coordinated care, which could save $1.1 billion over a five year period, HHS projects. The Centers for Medicare & Medicaid Services (CMS) Innovation Center is spearheading this initiative and will reward groups that have formed ACOs based on improvements in health of their Medicare patients and their ability to lower health care costs. Under the Pioneer ACO Model, the 32 selected health care organizations will test the effectiveness of several innovative payment models. The goal of the Pioneer ACO model is to provide better care for beneficiaries, improved coordination with private payers, a reduction Medicare cost growth, and rewards for health care providers that deliver high-quality care. The 32 selected Pioneer ACOs represent urban and rural organizations from various geographic regions of the country, covering 18 states and 860,000 Medicare beneficiaries.

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Categories: Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Key Developments

HHS releases bulletin on essential benefits, allows for state flexibility

Posted on December 16, 2011

The U.S. Department of Health and Human Services (HHS) has issued a pre-rule informational Bulletin which lays out its proposed approach for determining the Essential Benefits package required of all qualified health plans (QHPs) under the Affordable Care Act (ACA). HHS deferred to States’ judgment by allowing a State to create a benchmark essential benefits package from a currently-available plan within the State, as long as the package includes benefits from the ten benefit categories laid out in the ACA. HHS proposes that States choose the benchmark plan from a list of plan types:

One of the three largest small group plans in the State by enrollment
One of the three largest State employee health plans by enrollment
One of the three largest federal employee health plan options by enrollment
The largest HMO plan offered in the State’s commercial market by enrollment

If a State does not select a benchmark plan, HHS intends to propose that the default benchmark be the benefits package from the largest small group plan within the State.

For more information on Essential Benefits, click here.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Insurance, Key Developments, Office of Consumer Information and Insurance Oversight, Office of the Secretary, Rulemaking, Rules, and Guidance

Final Rule on CO-OPs released by HHS

Posted on December 9, 2011

The U.S. Department of Health and Human Services (HHS) has issued a final rule on the Consumer Operated and Oriented Plan (CO-OP) program. Created by the Affordable Care Act (ACA), the CO-OP program seeks to establish nonprofit cooperative insurance plans in all States. The ACA authorizes HHS to make loans available to eligible prospective CO-OPs, with the goal of creating one CO-OP per State. The ultimate intent is for CO-OPs to be able to offer affordable, qualified health plans (QHPs) to consumers through each State’s health insurance Exchange.

For more information on the CO-OP program, click here.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Insurance, Key Developments, Rulemaking, Rules, and Guidance

HHS issues MLR interim final rule

Posted on December 2, 2011

The U.S. Department of Health and Human Services (HHS) has issued an interim final rule (IFR), with public comment, on the medical loss ratio (MLR) requirement under the Affordable Care Act (ACA). Beginning in 2012, the ACA requires that health insurers spend at least 80% (in some cases 85%) of premiums on health care services, or be required to pay rebates to plan members. HHS issued both the rule itself as well as a separate IFR on the rebate requirements, each allowing for public comment.

For more information on medical loss ratios, click here. An update to the previous brief is pending.

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Categories: Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Insurance, Key Developments, Rulemaking, Rules, and Guidance

CMS announces new deadlines for Advance Payment Model

Posted on November 30, 2011

The Advance Payment Accountable Care Organization (ACO) Model is an initiative developed by the Centers for Medicare and Medicaid (CMS) Innovation Center designed for organizations participating as ACOs in the Medicare Shared Savings Program (Shared Savings Program). Through the Advance Payment Model, selected participants in the Shared Savings Program will receive advance payments that will be recouped from the shared savings they earn. CMS released a notice today announcing the new application deadline for participation in the Advance Payment Model for certain ACOs. Applications for the performance period beginning on April 1, 2012 will be accepted from January 3, 2012 through February 1, 2012. The period during which applications will be accepted for the performance period beginning on July 1, 2012 will remain identical to the period for the Medicare Shared Savings Program.

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Categories: Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Key Developments, Medicare

HHS announces release of tool for small businesses to compare health insurance plans

Posted on November 18, 2011

The U.S. Department of Health and Human Services announced the release of a greatly expanded website to give small business owners a venue to review health insurance plan choices. The tool enables small business owners to compare the benefits and costs of health plans and choose those that are best for their employees. Small businesses will be able to research locally available products in an unbiased manner. The aim of the tool is to foster a more transparent and competitive marketplace. At present, the market is often difficult to analyze and small businesses do not fare as well as their large employer counterparts when negotiating health care prices. Ideally, the new tool will help ensure insurance companies will compete for business on the basis of price and quality.

The tool was created under requirements contained in the Affordable Care Act (ACA). The Centers for Medicare & Medicaid Services collected information from insurers across the country to develop the site.

Information on the website includes:

Insurance product choices for a given ZIP code, sorted by out-of-pocket limits, average cost per enrollee, or other factors.
A summary of cost and coverage for small group products that shows the available deductibles, range of co-pay options, included and excluded benefits, and benefits available for purchase at additional cost.
The ability to filter product selection based on whether the plans are Health Savings Account eligible, have prescription drug, mental health, or maternity coverage, or allow for domestic partner or same sex coverage.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Key Developments