Health Insurance

Maintenance of Minimum Essential Coverage

Posted on February 10, 2012

Approximately 49 million nonelderly Americans are uninsured. Of those, approximately 20 percent have the financial means to buy health insurance but decide not to and instead rely on emergency care when necessary; the rest desire insurance but are denied coverage or cannot afford it. Even though uninsured, some individuals in the latter group receive medical services, resulting in approximately $43 billion worth of uncompensated care costs. These costs are recouped through higher charges for health care services, thereby producing a cost-shifting effect that results in higher premiums for those who are insured. This cost shift is…

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Categories: Health Insurance, Implementation Briefs, Implementation Update, Legal Challenges

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

Constitutional Challenges Update: Florida et al. v United States Department of Health and Human Services

Posted on January 4, 2012

On November 14, 2011 the United States Supreme Court agreed to hear oral arguments on issues that have arisen as a result of more than two dozen legal challenges to the Affordable Care Act (ACA) that were filed upon or immediately following the March 2010 enactment of the health reform law. The Court will consider four constitutional issues related to the ACA: (1) whether Congress has the power under Article I of the Constitution to enact the coverage requirement; (2) if the coverage requirement is found unconstitutional, whether it is severable from the remainder of the ACA; (3) whether the ACA’s requirement that states expand Medicaid eligibility or risk losing federal funds is unduly coercive in violation of the Tenth Amendment; and (4) whether the individual coverage requirement is a tax for purposes of the Anti-Injunction Act, meaning that plaintiffs seeking to challenge the requirement must wait until it takes effect in 2014.

Oral arguments are set for March 26-28, 2012, and a decision is expected by the end of the Court’s term in late June of 2012.

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Categories: Health Insurance, Implementation Briefs, Implementation Update, Judiciary, Legal Challenges

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

RWJF report explores Exchange options for States

Posted on December 20, 2011

The Robert Wood Johnson Foundation (RWJF) released a report today that explores three ways that states can comply with the Affordable Care Act’s (ACA’s) health insurance exchange provision. First, states can establish an exchange of their own; second, states can default to a federal exchange; or third, states can create a hybrid exchange. On behalf of the National Academy of Social Insurance (NASI), the authors evaluated the considerations associated with each option to help states determine which model may work best for the unique needs of their residents. Although the underlying goals are the same in all three Exchange models, there are differences in the amount of flexibility and autonomy granted to the States with each. State Exchanges, for example, offer the greatest independence in functions like coordinating plan enrollment, eligibility, and financial management. States cede much of this autonomy with the Federal Exchange model. As its name implies, the Hybrid Exchange allows states to retain responsibility for certain core functions, while importantly, also providing an interim pathway for an eventual State Exchange. The authors conclude that regardless of the model, success can only be achieved through intensive collaboration between individual states and the U.S. Department of Health & Human Services.

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Categories: Health Insurance, Library, Third Party Resources

Sen. Wyden (D-OR) joins Rep. Ryan (R-WI) on Medicare Plan

Posted on December 18, 2011

Democratic Sen. Ron Wyden of Oregon teamed up with Republican Rep. Paul Ryan of Wisconsin on a Medicare overhaul plan that would provide beneficiaries with a fixed amount to buy private coverage or pay for a traditional fee-for-service plan. Different from the Ryan plan introduced earlier this year, the Ryan-Wyden proposal would not do away with Medicare, but instead would leave it is an option for beneficiaries to purchase with their vouchers. However, this plan would not ensure that the voucher would make Medicare affordable, nor would it preclude private insurance policies from designing benefit plans to exclusively attract healthy beneficiaries.

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Categories: 112th Congress, Congressional Action, Health Insurance, Legislation, Medicare

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

GAO compares PCIP implementation with CHIP

Posted on December 15, 2011

The U.S. Government Accountability Office (GAO) has issued a report comparing the early stages of the federal Pre-Existing Condition Insurance Plan (PCIP) with the Children’s Health Insurance Program (CHIP). The federal PCIP was authorized by the Affordable Care Act (ACA), and is intended to provide insurance for individuals with previously existing medical conditions who have been unable to obtain health insurance coverage for at least 6 months. GAO was tasked by the Senate with comparing early enrollment and implementation across both PCIP and CHIP. GAO found that like CHIP, enrollment in PCIP was slow in the beginning, but increased over time. GAO also found that enrollment in PCIP was generally lower in States that had high risk pools than in States that did not.

For more information on pre-existing conditions, click here.

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Categories: Government Accountability Office, Health Insurance, Library, Medicaid and CHIP

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