Key Developments

CMS letter addresses enrollment strategies for Medicaid and CHIP

Posted on May 20, 2013

The Centers for Medicare and Medicaid Services (CMS) released a letter to state health officials and Medicaid Directors regarding enrollment of uninsured individuals into Medicaid and CHIP. With the looming enactment of the Affordable Care Act’s (ACA) provision on Medicaid expansion, CMS intends to assist states by providing optional tools that will aid in their transition to the new eligibility and enrollment models. The letter specifically addresses and provides guidance on these five enrollment strategies:

Implementing the early adoption of Modified Adjusted Gross Income (MAGI)-based rules;
Extending the Medicaid renewal period so renewals that would otherwise occur during the first quarter of calendar year 2014 will occur later;
Enrolling individuals into Medicaid based upon Supplemental Nutrition Assistance Program (SNAP) eligibility;
Enrolling parents into Medicaid based upon children’s income eligibility; and
Adopting 12-month continued eligibility for parents and other adults.

CMS purports that states choosing to utilize one of these outlined approaches will be met with a streamlined review and approval process.

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

CMS rule requires MA and Medicare Part D to comply with MLR

Posted on May 20, 2013

The Centers for Medicare and Medicaid Services (CMS) released a final rule that requires Medicare Advantage (MA) and Medicare Part D issuers to comply with the medical loss ratio (MLR), which states that these issuers must spend 85% of their premium revenues on patient services. The MLR permits only 15% of this revenue to be spent on organization administrative and overhead costs. MA and Part D issuers are required to submit data to CMS that allows consumers to use the sponsor’s MLR as a measure of efficiency. If the plan sponsors do not meet the MLR requirements, they will be subject to financial penalties, enrollment sanctions, and potential contract termination if issuers repeatedly miss the minimum MLR requirement.

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

CMS sets PCIP payment at Medicare rates

Posted on May 20, 2013

In an Interim Final Rule released Friday, the Centers for Medicare and Medicaid Services (CMS) stated that as of June 15th, payment rates for the federal Pre-Existing Condition Insurance Plan (PCIP) will be set to those of Medicare. Until the passage of the Affordable Care Act (ACA), many Americans with pre-existing conditions were denied insurance coverage or charged exorbitantly high premiums. PCIP, which was created under the ACA, was allocated $5 billion to enable those with pre-existing conditions to obtain insurance prior to 2014. 135,000 otherwise uninsured individuals with pre-existing conditions were granted coverage under PCIP, with claims averaging $32,108 per enrollee. Changes in PCIP payments were authorized in order to ensure program solvency until 2014. One specific example is the provision in which payments to skilled nursing facilities may be reduced by 50% as of June 15, 2013.

Enrollment in federal PCIP programs was capped in February due to funding concerns. Enrollment in the 27 state-operated PCIP programs was suspended several weeks later. As of now, 17 of the state-operated PCIP programs will be administered by the US Department of Health and Human Services (HHS) for the duration of the year.

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

CCIIO provides additional guidance on Navigators and Marketplace assistance

Posted on May 17, 2013

The Center for Consumer Information and Insurance Oversight (CCIIO) issued additional information on navigators and other consumer assistance and outreach programs provided by the Affordable Care Act (ACA). The document expands upon the standards with which these assistors must comply, available grant funding, and the differences between the assistance programs.

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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, Rulemaking, Rules, and Guidance

CCIIO releases Marketplace FAQ

Posted on May 17, 2013

The Center for Consumer Information and Insurance Oversight (CCIIO), a division of the Centers for Medicare and Medicaid Services (CMS), recently posted new guidance concerning federally-facilitated and state-based Exchanges (Marketplaces) established under the Affordable Care Act (ACA). The guidance purports that if states do not adhere to and enforce the requisite standards for health insurance issuers in federally-facilitated Exchanges, then CMS intends to coerce enforcement through civil penalties and plan decertification. CMS does not believe that decertification will be a common occurrence. In addition, the guidance stated that qualified health plans (QHP) paired with health savings accounts (HSA) must meet the cost-sharing reduction standards that apply to low income-individuals.

CCIIO published additional guidance that expands upon which activities, in both federally-facilitated and state-based Marketplaces, that qualify for grant funding under ACA Section 1311. For instance, state-based Marketplaces are not permitted to use this funding for navigator outreach and education, yet they are allowed to use Section 1311 funds for “in-person assistance programs.”

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CMS publishes FAQ on ECP

Posted on May 14, 2013

In a set of FAQ’s released yesterday, the Centers for Medicare and Medicaid Services (CMS) addressed the basics of Essential Community Providers (ECPs) within the Affordable Care Act (ACA). ECPs are health care providers that typically cater to medically needy, low-income individuals. Pursuant to the ACA, issuers that wish to offer qualified health plans (QHP) in health insurance Exchanges must have a sufficient number of ECPs geographically distributed throughout their networks. The FAQ set from CMS provides a basic outline of ECP criteria, including a link to a non-exhaustive list of ECPs and clarification on what CMS deems an “available” ECP.

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

IRS updates guidance with MLR proposed rule

Posted on May 14, 2013

According to a proposed rule released by the Internal Revenue Service (IRS), “activities that improve health quality” can not be used to determine Blue Cross and Blue Shield’s Medical Loss Ratio (MLR) in regards to obtaining their tax-exempt status. According to the Affordable Care Act (ACA), insurance companies lose their tax privilege under tax code Section 833 and the MLR if they do not spend 85% of their premium revenue on enrollee medical services. Until this proposed rule was released, interim guidance permitted insurance companies to count health care quality activities toward their 85%.

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Categories: Department of the Treasury, Health Insurance, Internal Revenue Service, Key Developments, Rulemaking, Rules, and Guidance

CMS releases DSH payment proposed rule

Posted on May 14, 2013

The Centers for Medicare and Medicaid Services (CMS) released a proposed rule concerning reductions to Disproportionate Share Hospital (DSH) payments. Pursuant to the Affordable Care Act (ACA), the federal government had intended to cut DSH payments beginning in 2014, as the law’s Medicaid expansion would negate the need for such payments. Since the Supreme Court’s decision rendered Medicaid expansion optional, the federal government has elected to delay the DSH payment reduction until 2015 when they have a more accurate assessment of the nation’s uncompensated care level after initial implementation of the ACA.

A fact sheet summarizing the rule can be found here.

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

CCIIO will amend Exchange regulations for Utah

Posted on May 10, 2013

In a letter addressed to the governor of Utah, Center for Consumer Information and Insurance Oversight (CCIIO) Director Gary Cohen stated that CCIIO will release updated regulations that will permit Utah to operate their small business health option program (SHOP) while the federal government runs the individual Exchange. The letter addresses how Utah and the federal government will divvy up responsibilities concerning navigators and plan management, as well as data reporting requirements for their SHOP. In addition, the letter purports that other states may also pursue a similar Exchange model.

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Categories: Department of Health and Human Services, Health Insurance, Key Developments, Office of Consumer Information and Insurance Oversight

EBSA preliminary guidance requires employers to notify employees about insurance options

Posted on May 10, 2013

The Employee Benefits Security Administration (EBSA), a division of the Department of Labor, published guidance concerning employer notification of insurance options in the health insurance marketplaces established by the Affordable Care Act (ACA), including model language for employers to notify their employees on marketplaces and employer-sponsored coverage. Technical Release Number 2013-02 states that employers must begin to inform their employees about available insurance options beginning October 1st, and the guidance contains a model notice for employers to utilize. EBSA released this guidance in advance of the proposed rule so that employers are equipped with the appropriate knowledge so they may begin to notify employees as soon as they desire.

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Categories: Department of Labor, Employee Benefit Security Administration, Health Insurance, Key Developments, Rulemaking, Rules, and Guidance