Health Insurance

Implementation Briefs

Maintenance of Minimum Essential Coverage

Categories: Health Insurance, Implementation Update, Legal Challenges

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...

Update to Consumer Operated and Oriented Plan (CO-OP) Program: Final Rule

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

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.

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

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

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.

Update: Essential Health Benefits

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

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

Employer Responsibilities under the Affordable Care Act

Categories: Health Insurance, Implementation Update

Posted on November 21, 2011

Under federal law, employers are not required to offer health insurance coverage to their employees; however, most do voluntarily. In fact, employer-sponsored health insurance is the primary source of health care coverage for most Americans, with roughly 60 percent of the non-elderly receiving health coverage through the workplace. Initially offered as a way to attract workers during wartime wage freezes and price controls, health insurance coverage is still used as a way to recruit and retain workers, and as a means of improving employees’ health and productivity. However, not all workers have health insurance. Indeed, three-fourths of the approximately 50 million uninsured Americans are working people and their dependents.

Hospital Readmissions Reduction Program

Categories: Health Care Quality and Delivery System Reform, Health Insurance, Implementation Update, Medicare

Posted on November 1, 2011

Hospitals in the United States readmit an average of 20% of Medicare patients within thirty days of their initial discharge. These readmissions cost the Medicare program an estimated 12 billion dollars each year and may be an indicator of poor quality of care where the readmission was potentially preventable. In its June 2007 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) classified many hospital readmissions as potentially preventable. Based on these recommendations, Congress included the Hospital Readmissions Reduction Program (HRRP or Program) in the Affordable Care Act. CMS issued the final rule implementing the HRRP on August 18, 2011, although CMS will continue to clarify additional details of the program through future rulemaking.

Update on Essential Health Benefits: The Institute of Medicine Report

Categories: Disparities, Health Insurance, Implementation Update

Posted on October 21, 2011

Under the Affordable Care Act (ACA) beginning January 1, 2014, state insurance Exchanges become operational and comprehensive insurance market reforms take effect. One of the most significant market reforms is the requirement that all health insurance plans sold in the individual and small group (100 employees or fewer) markets – whether sold outside or inside state insurance Exchanges – cover “essential health benefits” (EHBs). The definition of EHBs also will apply to Medicaid “benchmark” plans, the specified coverage standard for individuals made newly eligible by the ACA’s Medicaid expansions.

Legal Challenges Update: The Justice Department’s Petition for Writ of Certiorari in United States Department of Health and Human Services v. Florida

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

Posted on October 12, 2011

On September 28, 2011, the United States Justice Department (DOJ) asked the United States Supreme Court to review the decision of the court of appeals for the Eleventh Circuit striking down as unconstitutional what the DOJ terms the law’s “minimum coverage provision.” In seeking Supreme Court intervention, the DOJ sought review on two matters: first, whether Congress exceeded its Commerce Clause powers, as enhanced by the Necessary and Proper Clause; and second, whether the Anti-Injunction Act bars the challenges from proceeding in the first place.

Proposed Disclosure Rules Regarding Summary of Benefits and Coverage

Categories: Health Insurance, Implementation Update

Posted on September 30, 2011

The Affordable Care Act (ACA) included a new requirement that health plans in the group and individual markets disclose plan information to consumers in a standardized, accessible format in order to facilitate comparison of plans and improve understanding of plan terms. On August 22, 2011, several federal agencies jointly issued a notice of proposed rulemaking (NPRM) setting forth proposed disclosure requirements, including templates for the disclosures. Comments are due on October 21, 2011.

Update: Legal Challenges to the Affordable Care Act

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

Posted on September 23, 2011

Since the enactment of the Affordable Care Act (ACA), at least 27 lawsuits have been filed challenging the constitutionality of various provisions of the law. While nearly half of the lawsuits have been dismissed on procedural grounds, three district courts have found provisions challenged to be constitutional, and three have found them to be unconstitutional. Previous HealthReform GPS Implementation briefs/updates have discussed these lower court decisions. Following appeals of each of these rulings, the United States Courts of Appeals in the Fourth, Sixth, and Eleventh Circuits have now issued decisions as well. Most importantly, the appellate decisions continue to reflect a split in judicial opinion regarding the constitutionality of the Affordable Care Act’s individual mandate. Other important issues addressed by the appellate rulings concerned the constitutionality of the ACA Medicaid expansion and the question of whether the trial court in the Virginia cases (Liberty University v. Geithner and Commonwealth of Virginia v. Sebelius) had the authority to hear the cases at all.

Update: Health Insurance Premium Tax Credits

Categories: Health Insurance, Implementation Update, Tax Policy

Posted on September 2, 2011

This Update is the third in a series on a group of three regulations, all of which are summarized at HealthReformGPS.org. Together the rules are designed to implement both the Medicaid eligibility expansions, the process of determining eligibility for premium tax credits and cost sharing assistance in the Exchange individual market, and standards for employers purchasing coverage in Exchanges. Collectively, the rules are designed to allow individuals and families to acquire and keep coverage and move more seamlessly among publicly-supported sources of health insurance as family income and circumstances change.

Update to Health Insurance Exchanges–Exchange Functions in the Individual Market: Eligibility Determinations and Exchange Standards for Employers

Categories: Health Insurance, Implementation Update, Medicaid and CHIP

Posted on September 1, 2011

This Update to the health insurance Exchange Implementation Brief examines a proposed regulation issued on August 17, 2011 as part of three proposed rules to implement provisions of the Affordable Care Act related to health insurance affordability. Companion Updates explain the proposed Medicaid eligibility rule and the proposed rule related to health insurance premium tax credits; this Update focuses on Exchange functions related to determinations of eligibility for “Exchange participation and insurance affordability programs,” as well as standards for employer participation.

Update: Consumer Operated and Oriented Plan (CO-OP) Program

Categories: Health Insurance, Implementation Update

Posted on August 17, 2011

On July 20, 2011, the Centers for Medicare and Medicaid Services (CMS) issued a notice of proposed rulemaking (NPRM) with comments due September 16, 2011, regarding the Consumer Operated and Oriented Plan (CO-OP) program. 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 §1322(b)(2) of the ACA.

Update: Repeal of Free Choice Voucher Provisions

Categories: Health Insurance, Implementation Update

Posted on August 4, 2011

As discussed in the GPS Health Reform Overview, the Affordable Care Act (ACA) imposes penalties on large employers who do not offer affordable insurance to their employees if those employees receive subsidies to purchase insurance elsewhere. For certain employees, the ACA required employers to provide a voucher for purchase of insurance through a state Health Insurance Exchange. However, this “Free Choice Voucher” requirement was repealed on April 15, 2011, as part of an appropriations bill.

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

Categories: Health Insurance, Implementation Update, Medicare, Tax Policy

Posted on 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.

Update: Abortion Coverage

Categories: Health Insurance, Implementation Update

Posted on July 13, 2011

A previous Implementation Brief reviewed the provisions of Affordable Care Act (ACA) that restrict the use of federal funds for insurance coverage of abortion services. The ACA prohibits federal funds from being spent for coverage that includes abortion in the individual and group health plans sold in state Exchanges and it requires plans participating in an Exchange that offer abortion coverage to collect a separate premium from beneficiaries for that coverage and to pay for abortion-related services out of those segmented funds.

The Basic Health Program

Categories: Centers for Medicare & Medicaid Services, Disparities, Health Insurance, Medicaid and CHIP

Posted on June 29, 2011

An important issue in implementing the Affordable Care Act (ACA) is how to address the needs of uninsured low-income individuals and families whose incomes exceed Medicaid eligibility levels but are less than twice the federal poverty level (about $37,000 for a family of 3 in 2011). Under the ACA, the basic approach to assisting such individuals and families is the state health insurance Exchange, which enables qualified individuals to secure coverage and provides access to premium assistance and cost-sharing subsidies aimed at making coverage and care affordable.

The Consumer Operated and Oriented Plan (CO-OP) Program

Categories: Health Insurance, Implementation Update

Posted on June 22, 2011

During the debate that led to passage of the ACA, concerns were raised that millions of individuals and small groups lack sufficient choice among insurers in the existing private insurance market. Proponents (including those who sought a public insurance option) advocated for congressional investment in alternative sources of coverage in order to assure choice and competition, as well as to address the highly concentrated nature of the health insurance market (in most states 3 or fewer for-profit insurance companies account for over 65% of the market). A “public option” was proposed as a means of promoting an alternative to private coverage. In lieu of a public option, which proved highly controversial, the ACA included the Consumer Operated and Oriented Plan (CO-OP) program, whose purpose is to develop private non-profit alternatives to for-profit insurers. The central aim of the CO-OP program is to create consumer-run health insurers accountable to members, rather than to investors.

Update: Disclosure and Review of Unreasonable Premium Increases

Categories: Health Care Quality and Delivery System Reform, Health Insurance, Implementation Update

Posted on June 3, 2011

An earlier Implementation Brief provided an overview of the Disclosure and Review of Unreasonable Health Insurance Premium Rate Increases, which was established by §1003 of the Affordable Care Act (ACA) by adding §2794 to the Public Health Service Act (PHSA). On May 23, 2011, the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) published a final rule (with comment period) establishing a rate review program of “unreasonable” health insurance premium rate increases and implementing requirements for health insurance issuers regarding the disclosure and review of such unreasonable premium increases.

Essential Health Benefits: Overview of the Department of Labor Report on Benefits Offered Under a “Typical” Employer Health Plan

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on May 11, 2011

The Affordable Care Act (ACA) requires that all health insurance issuers offering products in the individual and small-group markets, including both the state Exchange market as well as the non-Exchange market, provide coverage of certain “essential health benefits.” An earlier Implementation Brief explored the concept of “essential health benefits.” This Brief summarizes a new U.S. Department of Labor (DOL) report on benefits covered in a “typical” employer plan and identifies key implementation issues for the federal Department of Health and Human Services (HHS).

Disclosure and Review of Unreasonable Premium Increases

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on April 14, 2011

Over the past decade, health insurance premiums have doubled (with particularly sharp increases in the small group and individual markets), making insurance coverage unattainable for millions of Americans. News stories have reported that some health insurers have sought to increase premium rates as much as 50 percent.

State Health Insurance Exchange Navigators

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on 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

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on 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.

Essential Benefits

Categories: Health Insurance

Posted on January 12, 2011

Prior to the enactment of the Affordable Care Act (ACA), federal law did not specify a standard minimum benefit package that must be covered by private health insurance and group health plans. The ACA not only bars discrimination in enrollment or the availability of coverage based on health status, but also establishes a minimum standard of coverage that must be satisfied by individual and small group health plans sold in both exchange and non-exchange markets, as well as by any qualified health plan sold in the state exchange market, regardless of group size.

Tax Subsidies for Individuals and Families Who Purchase Coverage Through State Health Insurance Exchanges

Categories: Health Insurance, Tax Policy

Posted on December 9, 2010

This Implementation Brief Includes Tax Subsidy Amendments Passed by the Senate as of December 9, 2010.

The Affordable Care Act (ACA) establishes a refundable tax credit for individuals without affordable employer coverage and ineligible for Medicaid:

Update: Medical Loss Ratio and Rebates in Private Health Insurance

Categories: Health Insurance

Posted on November 23, 2010

This is an updated version of a brief originally published on August 25, 2010. This brief is current as of November 22, 2010. A medical loss ratio (MLR) is the proportion of premium dollars that an insurer spends on health care services relative to health insurance premium paid by subscribers. Prior to the enactment of the health reform law, the federal government required Medicare supplemental insurance (or Medigap policies) to meet minimum federal loss ratio requirements, but did not establish federal standards to define how insurers should categorize losses, nor did those requirements apply to other types of private insurance policies.

Update: Health Insurance Exchanges

Categories: Health Insurance

Posted on November 22, 2010

The Affordable Care Act establishes “American Health Benefit Exchanges” (serving individuals) and “SHOP” Exchanges (serving small employer groups), to be operated by states that elect to establish exchanges for individuals and employer groups through which they can buy “qualified health plans.”

Update: Health Insurance Reforms and “Grandfathered Plans”

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on November 17, 2010

The health reform law establishes minimum federal standards, preserving states’ ability to require more stringent standards for insured plans.

Health Reform and ERISA

Categories: Health Insurance

Posted on September 27, 2010

The Patient Protection and Affordable Care Act (PPACA or the Act) changes ERISA in important ways that increase participant and beneficiary rights, while at the same time leaving its basic requirements and framework untouched.

Employer Wellness Programs

Categories: Health Insurance

Posted on August 16, 2010

One objective of the insurance reform provisions of the health reform law was to continue the policy begun under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to encourage individuals and their families to be more engaged in their health care and to adopt healthier lifestyles.

Abortion Coverage

Categories: Health Insurance

Posted on June 6, 2010

The health reform law establishes restrictions on abortion coverage in the case of individual and group health plans sold in state exchanges.

Immediate Private Health Insurance Reforms

Categories: Health Insurance

Posted on May 10, 2010

Although most changes in health insurance access rules are not effective until 2014, a number of reforms are designed to go into effect more quickly. These changes apply to health insurance issuers in the group and individual insurance markets as well as to self-funded group health plans and multiple employer welfare arrangements (MEWAs).

High Risk Pools for Uninsured Persons with Pre-Existing Conditions

Categories: Health Insurance

Posted on April 22, 2010

Provides funding for a temporary high-risk health insurance pool for individuals with pre-existing conditions.