CMS issues health IT guidance on state exchanges

Posted on June 6, 2011 | No Comments
Filed under Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Information, Key Developments, Rulemaking, Rules, and Guidance

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Key Developments

The Centers for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services has issued an updated guidance to assist states as they design, develop, and implement health IT systems for health insurance exchanges mandated under the Affordable Care Act (ACA). The guidance addresses significant structural and business architecural components of the exchange framework, and is designed to promote a “high quality customer experience.”

One highlight of the guidance is a description of the “data services hub” that CMS plans to establish and is designed to help states verify citizenship, immigration status, and income of applicants for health plans offered on the exchanges. Under the ACA, the American Health Benefits Exchanges must be up and running by January 1, 2014.

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New report explores federal plan management of the Exchanges

May 10, 2012

Health insurance exchanges are a provision under the Affordable Care Act (ACA) and must engage in five core functions: 1) determine eligibility for federal subsidies or public coverage, 2) enroll consumers and employees into qualified health coverage (or connect eligible individuals with Medicaid and CHIP), 3) conduct plan management, 4) provide consumer assistance, and 5) perform financial management. The Center on Health Insurance Reforms at Georgetown University Health Policy Institute and the National Academy of Social Insurance (NASI), with funding from the Robert Wood Johnson Foundation (RWJF) recently released a paper focuses on one of these core functions: the series of oversight activities that federal officials have called “plan management.” States face three choices: establish their own exchange and exercise control over plan management functions, allow the federal government to establish a federally facilitated exchange (FFE) but enter into a partnership arrangement to perform plan management, or cede all plan management functions to the FFE. With the latter two approaches, the state will essentially turn over to the federal government some of its traditional authority to regulate its private health insurance markets. However, through a partnership arrangement, state regulators can recapture that authority and oversight. The U.S. Department of Health and Human Services (HHS) has defined plan management to...

New GW/Commonwealth paper examines multi-state plans

April 16, 2012

A new paper titled, “Multi-State Plans under the Affordable Care Act,” was recently released by the George Washington University School of Public Health and Health Services. Authored by Trish Riley and Jane Hyatt Thorpe of the GW Department of Health Policy and funded by The Commonwealth Fund, the paper examines key issues related to the development of multi-state plans (MSPs), a new type of insurance coverage created by a provision of the Affordable Care Act (ACA). MSPs will be administered through the federal Office of Personnel Management (OPM) and offered across state lines through the new state health insurance exchanges. The findings in this paper are based on interviews with federal and state policy makers and other stakeholders, and are intended to inform the development and implementation of MSPs. A primary goal of the ACA is to...

New RWJF project examines health reform progress

March 30, 2012

A series of in-depth case studies based on site visits and reports from national data sets tracks how the Affordable Care Act (ACA) is being implemented in states and establishes a baseline for measuring progress over the coming years. The reports, prepared by researchers at the Urban Institute and Georgetown University’s Health Policy Institute, are designed to share background information, processes, and learnings that can inform the work of state government agencies, policy-makers, and others across the country as ACA implementation progresses. In the first reports, the authors found that...

NASHP report on Exchanges focuses on individual states

March 6, 2012

The Affordable Care Act's Health Benefit Exchanges (Exchanges) must be implemented in every state by January 1, 2014. The development of Exchanges will have a significant impact on how consumers access and sign up for coverage. National Academy of State Health Policy (NASHP) established the State Health Exchange Leadership Network, "a peer learning network for exchange leads." The purpose of the Network is to foster interaction and education as states move ahead with the design, construction, and execution of the Health Benefits Exchange market. This report examines key consumer-related issues and challenges that states must tackle as they plan and implement their Exchanges. Three main areas where consumers intersect with the Exchange are covered in the report...

Update: Exchanges Establishment and Eligibility Final Rule

April 10, 2012

The Department of Health and Human Services (HHS), Center for Medicare and Medicaid Services (CMS) has issued a final rule^[1] addressing two previous proposed rules: “Establishment of Exchanges and Qualified Health Plans”^[2] and “Exchange Functions in the Individual Market: Eligibility Determinations and Exchange Standards for Employers.”^[3] The final rule addresses 1) minimum federal standards that States must meet to establish and operate exchanges, 2) the minimum standards that health insurance issuers must meet as Qualified Health Plans (QHPs), and 3) basic standards employers must meet to participate in the Small Business Health Options Program (SHOP) Exchange. CMS indicates that certain portions of the rule will be considered interim final, and the agency will accept comments on certain sections.^[4] CMS also indicates in the Preamble that additional details will be made available in future guidance and rulemaking, where appropriate. For information on the proposed rules, click here. This Update describes major changes made by CMS in the final rule.

Health Insurance Exchanges Update: Qualified Health Plans, Reinsurance, Risk Corridors and Risk Adjustment

July 19, 2011

A major problem in the U.S. health care system is the lack of affordable health insurance options for individuals and small businesses. These groups also have no easy way to compare plans in terms of premium cost, benefits and cost sharing, provider networks, or quality of care provided. The Affordable Care Act (ACA) seeks to address these problems by making private health insurance available to qualified small businesses and individuals through health insurance Exchanges beginning January 1, 2014.

State Health Insurance Exchange Navigators

February 28, 2011

One of the great challenges of our health care system for individuals and small employers is figuring out health insurance. Multiple products are available in the market, and they can differ enormously with respect to benefits and cost-sharing, coverage standards, who – and what – is in or out of provider networks, and how to make the best use of insurance coverage. Insurance agents and brokers – sometimes referred to as “producers” – provide an important service by helping people and small businesses make purchasing choices. But brokers and agents perform a specific task: their primary job is to sell insurance products. Thus, while their role is key to a functioning insurance market, brokers and agents may not be sources of impartial advice on how to select among competing plans, and they may not provide post-enrollment assistance in understanding and using coverage once purchased.

Value-Based Health Care Purchasing: Essential Health Benefits and State Health Insurance Exchanges

January 25, 2011

Bringing down the overall cost of health care while improving its quality for all Americans represents one of the central goals of health reform. Although reducing the number of people without health insurance will provide relief by curtailing much of the estimated $50 billion in annual cost-shifting onto the insured, the longer term challenges are more complex, because they involve structural change in how health care is organized, delivered, and paid for. Specifically, improving health care quality while reducing costs means doing two things simultaneously: moving away from a fragmented system oriented toward what has been termed a “piecework” approach to health care; and introducing new approaches that reward greater clinical integration and efficiencies aimed at creating equally effective but lower-cost care. To achieve these results, the concept of “value-based purchasing” has received increased attention.

HHS releases final rule on Medicaid eligibility

March 16, 2012

Today the U.S. Department of Health and Human Services released the final rule for Medicaid program eligibility changes under the Affordable Care Act (ACA). Similar to the exchange final rule, certain provisions of the Medicaid final rule were issued as interim final, with a 45 day comment period. Under the ACA, individuals between ages 19 and 64 with incomes up to 133 percent of the federal poverty level (currently $14,856 for an individual and $30,656 for a family of four) are eligible for Medicaid coverage. Medicaid expansion will become effective in 2014 when the Exchanges begin operation. The federal government will pay 100 percent of the association expansion cost for the first three years and at least 90 percent after that. The final rule announced today deviates from the August 2011 proposed rule enrollment rules. The proposed rule would have given the Exchanges the responsibility of determining who is eligible for Medicaid in order to facilitate "one-stop shopping" for coverage options. Under the final rule, however, states will now be able to choose whether the Exchange will enroll people in Medicaid or whether the state Medicaid agency alone will have that power.

HHS publishes final rule on Exchanges

March 12, 2012

The U.S. Department of Health and Human Services (HHS) published a final rule on the Affordable Health Insurance Exchanges (Exchanges) this morning. The publication combines policies from two Notices of Proposed Rulemaking (NPRMs) released last summer. The first outlined a proposed framework to enable states to build Exchanges and the second outlined standards for eligibility for enrollment in qualified health plans (QHPs) through the Exchange market. Starting in 2014, Exchanges will be operational...