Implementation Briefs
CMS State Resources FAQ: Medicaid Eligibility Determinations, Medicaid/Exchange Interactions, and §1115 Demonstrations that Use Enrollment Caps
Posted on May 22, 2013
The interaction between Medicaid and Exchanges around eligibility determination issues represents one of the most important and complex aspects of the ACA. An estimated 28 million adults, along with 19 million children, can be expected to transition at least once annually between insurance affordability programs, as Medicaid and premium subsidies are termed under implementing CMS regulations. Collaboration between Medicaid agencies and Exchanges is essential in order to avert unnecessary delays in eligibility determinations and breaks in coverage that in turn can affect not only the affordability of care but access itself, given the link between coverage and health care access through plans’ provider networks…
Update: Frequently Asked Questions on Patient Cost-Sharing Under the ACA – Set 12
Posted on May 16, 2013
The ACA contains numerous provisions affecting patient cost-sharing, both generally and in relation to specific services. Some of the provisions (such as those related to preventive services and annual limits on out-of-pocket cost-sharing) apply across multiple coverage markets (i.e., to health insurance products sold in both the individual and group markets as well as to self-insured plans). Other provisions, such as those governing deductibles applicable to the essential health benefit (EHB) package, apply only to those markets that are subject to the EHB requirement, i.e., health plans sold in the individual and small group (under 100 full-time employees) market. In general, the cost-sharing rules exempt grandfathered health plans.
Final Rule: Notice of Benefit and Payment Parameters for 2014
Posted on May 8, 2013
On March 11, 2013, the U.S. Department of Health and Human Services (HHS) released a final rule on the Notice of Benefit and Payment Parameters for 2014. This final rule addresses a variety of issues, including the specific payment parameters for the three premium stabilization programs – the permanent risk adjustment program, the transitional reinsurance program, and the temporary risk corridors program. In addition, the final rule also covers advance payments of the premium tax credit, cost-sharing reductions, and user fees for the federally-facilitated Exchanges, specific requirements related to the federally facilitated Small Business Health Option Program (SHOP), and the medical loss ratio program. This rule finalizes the provisions set forth in HHS’s proposed rule on these topics, December 7, 2012…
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Interim Final Rule: Alternative Approaches to Cost-Sharing Reduction Payment and Risk Corridor Calculations
Posted on May 8, 2013
The temporary risk corridors program allows the federal government to share a QHP’s profits or losses among other QHP issuers due to inaccurate rate setting inside the Exchanges from 2014-2016. To determine whether a QHP issuer has inaccurately set premium rates that lead to an unjustified profit or loss, a QHP’s “allowable costs” must be calculated per the requirements in the Premium Stabilization Rule. The IFR modifies the definition of “allowable costs” such that a QHP’s allowable costs are to be determined based on its pro-rata share of the QHP issuer’s incurred claims for all non-grandfathered health plans within a state, and allocated to the QHP based on premiums earned by the issuer in the market…
Sub-Regulatory Guidance Regarding Age Curves, Geographical Rating Areas and State Reporting
Posted on May 1, 2013
This Age Curve portion of the sub-regulatory guidance reminds states that in the absence of a state-established and HHS-approved uniform age rating curve for the purpose of age rating in the individual and small group markets, a federal default standard will apply. The statute and final rule require that the premium rate charged by an issuer in the individual and small group market (for non-grandfathered plans) may vary by age, but not by more than a 3:1 ratio for adults. Moreover, the final rule defines, and the sub-regulatory guidance reiterates, the standard age bands for insurance rating purposes as follows…
Navigators and Application Counseling and Assistance
Posted on April 24, 2013
The ACA (§§1311(d) and (i)) and implementing regulations (45 C.F.R. §155.210) require that all Exchanges establish Navigator programs to provide fair, accurate and impartial information regarding health insurance coverage across Exchanges and state Medicaid and CHIP programs. Navigators also facilitate selection of QHPs and provide referrals for consumers with questions, complaints, or grievances to other consumer assistance and ombudsman programs. The Navigator program requirement applies regardless of whether the Exchange is operated by a state government or by the federal government (known as a “federally-facilitated Exchange”), either with or without a state Consumer Assistance Partnership…
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Update: Treasury/IRS Proposed Rule on Community Benefit Obligations of Nonprofit Hospitals
Posted on April 17, 2013
Prior to 1969, nonprofit hospitals, as a condition of their tax-exempt status, were expected to furnish uncompensated care to persons unable to pay. In 1969, the Nixon Administration broadened this obligation to encompass “community benefits,” which could take the form of not only free or reduced-cost care, but also other activities that hospitals determined would benefit their communities, such as health promotion activities, research, and education and training. This more amorphous concept of community benefit went unenforced for decades. However, following years of government reports and news stories focusing on the limited level of uncompensated care furnished by many nonprofit hospitals, as well as the imposition of excessive charges and use of harsh billing practices on the uninsured, Congress moved to address the issue…
Update: Using Medicaid to Provide Premium Assistance for Exchange Coverage
Posted on April 10, 2013
This update to our previous Implementation Brief on states’ option to implement Medicaid coverage by enrolling beneficiaries into Qualified Health Plans sold in Exchanges examines Frequently Answered Questions on Medicaid and Premium Assistance (“FAQ”), released on March 29th by CMS. The FAQ answer some, but not all, questions raised by this approach to implementation of the ACA Medicaid expansion…
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Access to Pediatric Oral Health Benefits offered through Health Insurance Exchanges
Posted on April 4, 2013
This Implementation Brief examines current Administration policy regarding access to children’s oral health benefits among families who qualify both for Exchange coverage and for advance premium tax credits and cost-sharing reduction assistance. The Brief identifies an emerging set of policy issues that in turn may be creating a policy misalignment between children’s oral health coverage and the premium credits and…
Multi-State Health Plans: The Final Rule
Posted on April 3, 2013
The state health insurance exchanges are designed to provide consumers choices among pre-approved health plans that meet certain federal standards ranging from the provision of specific benefits to anti-discriminatory requirements for pre-existing health conditions. Only plans that meet these standards – the qualified health plans, or QHPs – will be allowed to participate in the exchanges. To further foster competition, the ACA also requires two QHPs participating in each exchange to be multi–state plans…
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Most Popular Content
- State Health Insurance Exchange Navigators posted on February 28, 2011
- The QHP Certification Process in Federally-Facilitated Exchanges: Network Adequacy and Essential Community Providers posted on March 27, 2013
- Summary of the U.S. Supreme Court decision in the case of National Federation of Independent Businesses et al. v. Sebelius, Secretary of Health and Human Services, et al. posted on June 28, 2012
- Update: Essential Health Benefits Final Rule posted on March 13, 2013
- Reform Overview posted on April 12, 2010
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Recent Posts
- CA releases proposed premium rates for 2014
- NEJM article correlates decline in health spending to recession
- EBRI study explores trends in part-time health coverage
- CO releases 2014 Exchange rates
- CMS State Resources FAQ: Medicaid Eligibility Determinations, Medicaid/Exchange Interactions, and §1115 Demonstrations that Use Enrollment Caps
- CMS letter addresses enrollment strategies for Medicaid and CHIP
- WA releases Exchange premiums
- CMS rule requires MA and Medicare Part D to comply with MLR
- CMS sets PCIP payment at Medicare rates
- CCIIO provides additional guidance on Navigators and Marketplace assistance
