Tag: CMS
Update: Medical Loss Ratio Requirements
Posted by Mark Dorley on May 15, 2012
On May 11, 2012, the United States Department of Health and Human Services (HHS) issued a final rule that revises previous medical loss ratio (MLR) rules to establish consumer notification requirements with which insurers must comply when meeting applicable MLR requirements. In a previous December, 2011 final rule governing other aspects of the MLR amendments, HHS had required notification only when insurers did not …
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CMS releases final rule on MLR requirements
Posted by mmcdowell on May 12, 2012
The Centers for Medicare & Medicaid Services (CMS), a department within the U.S. Department of Health and Human Services (HHS), released final rules on Friday May 11th requiring insurers to notify subscribers when the medical loss ratio (MLR) provision of the Affordable Care Act (ACA) is met or exceeded for spending on medical claims or quality improvements. The December 2011 interim final rule and final rule on MLR only required that notices be sent to policyholders when insurers did not meet the MLR requirements.
The ACA requires both individual and small group plans to meet the MLR requirements by spending at least 80 percent of premiums on medical claims or quality improvements. Large plans are required to spend at least 85 percent. Beginning in August of 2012, insurers must refund the difference to consumers.
The goal of the notice is to educate consumers regarding the MLR measures and to help consumers know that the majority of premium payments go towards health care, as opposed to advertising, executive bonuses, or administrative overhead costs.
HHS said the rule is not expected to have an economic impact of more than $100 million a year.
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HHS releases two rules to streamline regulations for hospitals and providers
Posted by mmcdowell on May 10, 2012
Today, the Centers for Medicare & Medicaid Services (CMS) released two final rules. The first rule revises the Medicare Conditions of Participation (CoPs) for hospitals and critical access hospitals (CAHs). CMS estimates that annual savings to hospitals and CAHs will be approximately $940 million per year. The second, the Medicare Regulatory Reform rule, will produce savings of $200 million in the first year by promoting efficiency. This rule eliminates duplicative, overlapping, and outdated regulatory requirements for health care providers.
Among other changes, the final rules will…
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CMS releases proposed rule to increase Medicaid payments
Posted by mmcdowell on May 9, 2012
Today the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS), released a proposed rule on Medicaid payments. The proposed rule would implement Medicaid payment for primary care services furnished by certain physicians in years 2013 and 2014 at rates not less than Medicare rates in effect in that time period. The rule would apply to physicians who practice family medicine, general internal medicine, or pediatric medicine, and to services paid through Medicaid managed plans. The proposal also permits providers to charge higher rates for vaccinations under the federally backed Vaccines for Children program. CMS estimated the provision will cost the government $5.5 billion the first year, and $5.6 billion in the second.
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Update: Essential Health Benefits FAQs
Posted by Mark Dorley on
In February 2012, CMS issued a supplemental document entitled Frequently Asked Questions on Essential Health Benefits Bulletin. This supplement to the December 16th Bulletin provides answers to 22 questions arising from the December 16th Bulletin itself. Highlights are as follows:
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CMS issues final and proposed rules on Medicaid and community-based services
Posted by mmcdowell on May 7, 2012
The Centers for Medicare & Medicaid Services (CMS) issued final and proposed rules on April 26 giving states more flexibility regarding community-based services and support for Medicaid enrollees. The regulations were published in today’s Federal Register.
The final rule implements section 2401 of the Affordable Care Act (ACA), which establishes a new State option to provide home and community-based attendant services and supports. These services and supports are known as Community First Choice (CFC). The regulation provides an incentive for states to expand Medicaid coverage for home and community-based services by boosting the federal match rate. To qualify for this improved federal match rate, a state must agree to develop its Community First Choice benefit, maintain a quality assurance system, and collect and report information to CMS. Additionally, during the first 12 months of Community First Choice benefit implementation, the state must maintain or exceed the level of expenditures for home and community-based services provided under the state plan, waivers or demonstration for the preceding 12 months. While this final rule sets forth the requirements for implementation of CFC, it does not finalize the section concerning the CFC setting. CMS estimated that the final rule would have an impact of $1.3 billion in FY 2012.
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CMS takes steps to improve transparency of demonstration waiver process
Posted by mmcdowell on April 30, 2012
The Centers for Medicare & Medicaid Services (CMS) issued guidance on Friday, April 27 regarding the process the agency will use to review and approve state demonstration projects under Medicaid and the Children’s Health Insurance Program (CHIP). The guidance outlines how CMS plans to implement requirements for improving public input and transparency with regard to the demonstration projects. These “1115 Waivers” authorize states to test new coverage and delivery models after obtaining appropriate waivers from CMS.
The guidance, accompanied by a letter to state Medicaid directors, also introduces the user guide that CMS is providing for stakeholder organizations.
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Three federal agencies release request for information on stop-loss coverage
Posted by mmcdowell on
On April 27, 2012, the Department of the Treasury’s Internal Revenue Service (IRS), the Department of Labor’s Employee Benefits Security Administration, and the Department of Health and Human Services’ (HHS) Centers for Medicare & Medicaid Services (CMS) issued a request for information (RFI) regarding the use of stop loss insurance by group health plans and their plan sponsors, with a focus on the prevalence and consequences of stop loss insurance at low attachment points, or the point at which excess insurance or reinsurance limits apply.
Concerns have circulated that the practice could lead to higher costs in small group health insurance exchanges. Stop-loss insurance protects self-insured companies against claims above the attachment point. Employers and plans that purchase stop-loss insurance generally are not subject to state health insurance laws regarding coverage, rating policies, and other state and federal consumer protections, and thus could prove financially risky in the exchange market. Specifically, if the practice is widespread, it could worsen the risk pool and increase premiums in the insured small group market, including the Small Business Health Options Program (SHOP) exchanges.
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CMS releases bulletin providing MLR guidance
Posted by mmcdowell on April 25, 2012
The Center for Consumer Information and Insurance Oversight (CCIIO), a division of the Centers for Medicare and Medicaid Services (CMS) recently released a bulletin providing medical loss ratio (MLR) guidance. Section 2718 of the Public Health Service Act (PHS Act), as added by the Affordable Care Act (ACA), requires health insurance issuers to submit a MLR report to the Secretary. The PHS Act also requires issuers to provide a rebate to enrollees if the issuer’s MLR is less than the applicable percentage established in the PHS Act. The CCIIO bulletin covers the following topics:
- Applicability of the Medical Loss Ratio to Certain Types of Plans
- Employer Groups of One
- Counting Employees for Determining Market Size
- Individual Association Policies
- Offering Policyholders a “Premium Holiday”
- Reinsurance and Reporting
- Exchange User Fees
- States With a Higher Medical Loss Ratio Standard
- “Mini-Med” Experience – Application of the Adjustment
- Form of Rebate
CMS issued a final rule implementing MLR requirements and an interim final rule implementing MLR rebate requirements in December 2011.
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Urban paper shows progress in controlling Medicare costs
Posted by mmcdowell on April 24, 2012
Americans have been engaged in an ongoing debate regarding the size of the federal deficit. Medicare and Medicaid spending are often implicated in these discussions. Some have called for a significant restructuring of both programs—premium support for Medicare and block grants for Medicaid. Reform proposals focus on reducing the rate of growth in spending in both programs to a rate close to the increase in economic growth. In a paper recently released by the Urban Institute, authors show that spending in both programs has been significantly affected by enrollment growth, but that both the Centers for Medicare and Medicaid Services (CMS) and the Congressional Budget Office (CBO) project spending growth per enrollee in both programs to be less than private insurance expenditures and to be close to the growth in gross domestic product (GDP) per capita.
The paper concludes that…
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- Update: Medical Loss Ratio Requirements
