A project of the George Washington University's Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation

Implementation Brief CMS 2015 Draft Letter to Issuers in the Federally Facilitated Marketplace: Network Adequacy and Inclusion of Essential Community Providers

Posted on March 5, 2014 | Comments Off

In administering the FFM, CMS utilizes Issuer Letters to apprise issuers potentially interested in offering qualified health plans (QHPs) in the Marketplace regarding priorities and policies for the agency. In effect, CMS acts like a plan sponsor in managing the FFM, although unlike other sponsors (e.g., employers), the FFM has not, to date, been selective about which plans may be sold in the Marketplace. That is, plans that meet FFM (and where applicable, state) certification standards are eligible to be sold. At the same time, QHPs must meet a range of certification standards, and in its oversight capacity, CMS uses its Issuer Letters as a means of clarifying policy and delineating areas of emphasis for health plans.

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CMS guidance permits retroactive subsidy access

Posted on February 28, 2014 | Comments Off

Guidance issued by the Center for Medicare and Medicaid Services (CMS) states that individuals who enrolled in health plans outside of the Affordable Care Act (ACA) insurance Marketplaces may retroactively receive premium subsidies. Under the ACA, advanced premium tax credits, or subsidies, are only available to individuals that purchased qualified health plans through the Marketplace. Many states have asked CMS to permit subsidies outside of the ACA Marketplace because IT issues prevented many eligible individuals from enrolling into QHPs before the deadline. Subsidies will retroactively be paid to insurers back to the effective date of plan enrollment.

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CMS issues DSH allotments

Posted on February 27, 2014 | Comments Off

The Centers for Medicare and Medicaid Services (CMS) issued the funding allocation for disproportionate share hospitals (DSH) for FY 2014. DSH payments are typically provided to hospitals that treat a disproportionate number of uninsured or under-insured patients. The Affordable Care Act (ACA) originally called for a cut in DSH payments, as more Americans would presumably be insured under Medicaid. The Supreme Court ruling that made Medicaid expansion optional, however, ultimately coerced CMS to delay DSH cuts for two years.

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CMS report addresses small business premiums

Posted on February 25, 2014 | Comments Off

The Centers for Medicare and Medicaid Services (CMS) released a report to Congress late last week discussing the impact of the Affordable Care Act (ACA) on small business premiums. The report, mandated by the Budget Control Act, found that health insurance premiums for 11 million small business employees would likely rise under the ACA, while premiums for 6 million small business employees would decrease. Evidence as to how much premiums will rise for small business employees under the ACA is currently inconclusive.

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Tri-agency rules address 90-day waiting period limit

Posted on February 20, 2014 | Comments Off

The US Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA) released several rules today concerning the 90-day waiting period limitation before insurance coverage can become effective. The final rule states that group health insurance plans cannot apply a waiting period that exceeds 90 days beginning January 2015. The proposed rule clarifies the 90-day limitation in terms of the length of employment-based orientation periods, stating that one month is the reasonable limit for employment-based orientation periods.

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GAO report finds states spend one-third of Medicaid dollars on few beneficiaries

Posted on February 20, 2014 | Comments Off

The Government Accountability Office (GAO) released a new report citing how Medicaid spends a third of their funds on a small sect of high-expenditure Medicaid beneficiaries. The report, Medicaid: Demographics and Service Usage of Certain High-Expenditure Beneficiaries, found that states spent 31.6% of all Medicaid expenditures on 4.3% of the Medicaid population. Furthermore, the report stated that certain characteristics, such as residing in a long-term care facility, contributed to individuals being deemed high-expenditure Medicare beneficiaries.

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Expert Commentary on Stand Alone Dental Plan Cost-Sharing from the Children’s Dental Health Project

Posted on February 19, 2014 | Comments Off

The US Department of Health and Human Services (HHS) is currently finalizing the Notice of Benefit and Payment Parameters for 2015 , a rule that proposes, among other things, to tweak the cost-sharing limits and eliminate the actuarial value (AV) standards for dental plans offering pediatric dental coverage in the marketplaces.

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CMS bulletin allows individuals to change insurance plans

Posted on February 11, 2014 | Public Comment (1)

Guidance recently released by the Centers for Medicare and Medicaid Services (CMS) states that individuals who have paid their first month’s premium and have already received coverage may change their insurance plan in order to obtain a more robust provider network. The guidance, which consists of five bulletins, provides information for both issuers and consumers in federally-facilitated and state-partnership marketplaces regarding the ability to alter application information or plan selections based upon certain life events or changes in enrollment periods.

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IRS rule addresses employer mandate, calculating teacher hours

Posted on February 11, 2014 | Comments Off

A new rule issued by the Internal Revenue Service (IRS) addresses several components of the employer shared responsibility provisions within the Affordable Care Act (ACA). The rule further delays the employer shared responsibility payment for medium-sized businesses (50-100 employees) until 2016. Large employers will be able to phase in the percentage of full-time employees to whom they must provide health insurance, starting with 70% in 2015 and moving to 95% by 2016. IRS also released a fact sheet to accompany this rule. Additionally, this rule stated that teachers cannot be considered part-time employees because many do not work a full summer schedule.

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Implementation Brief When Does Medicaid Coverage Amount to Minimum Essential Coverage Under the Affordable Care Act? An Update on the Treasury/IRS Rules Defining Minimum Essential Coverage

Posted on February 11, 2014 | Comments Off

A January 27, 2014 proposed rule in the Federal Register (79 Fed. Reg. 4302-4308) published by Treasury/IRS would add further clarification to the question of under what circumstances the agencies will classify Medicaid as minimum essential coverage (MEC) for purposes of satisfying the Affordable Care Act’s requirement to maintain MEC or pay a shared responsibility tax. Comments are due by April 28, 2014; the agencies also intend to hold a public hearing on the NPRM which covers Medicaid as well as other types of coverage.

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