CMS issues Medicare Advantage and Part D final rule for 2015

Posted on May 21, 2014 | Comments Off

The Centers for Medicare and Medicaid Services (CMS) issued the final rule for Medicare Advantage (Part C) and the Medicare prescription drug benefit program (Part D) for contract year 2015. The rule aims to clarify program provisions, enact statute requirements, and improve payment accuracy. One specific provision provided in the rule said CMS will not open up preferred networks to permit any willing pharmacy to offer preferred cost-sharing. CMS indicated they would continue to study preferred cost-sharing practices to address stakeholder reactions and concerns to the proposed policy.

Continue Reading »

HHS releases final Marketplace rule

Posted on May 16, 2014 | Comments Off

The US Department of Health and Human Services (HHS) issued a final rule entitled Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond. Some specific provisions in the rule include:

  • Raising the administrative costs and profits ceiling under the risk corridor formula by 2%.
  • Providing information on how to include ICD-10 costs under the medical loss ratio (MLR).
  • Requiring qualified health plans (QHP) on the ACA Marketplace to have a more efficient and effective method for enrollees to acquire medications not covered on the plan. This specifically applies to enrollees on a course of treatment in which absence of the medication would substantially impact the individual’s life and health.
  • Requiring insurers to annually report plan changes to beneficiaries.
  • Beginning in 2016, Marketplaces will have to display quality data on all plans for public viewing. The data will be based on a five-star system and enrollee satisfaction surveys.
  • Enumerating state requirements that may prohibit Navigators or other assistors from performing their roles. For example, Navigators may go door-to-door for enrollment assistance and outreach. They may not, however, provide gifts to entice enrollment.
  • Delaying the “employee choice” option in the small business health options program (SHOP) to 2016.

The final rule is largely unchanged from the proposed version. An FAQ addressing market reforms and Marketplace standards can also be accessed here.

Continue Reading »

Exemptions and Special Enrollment Periods under the ACA

Posted on May 14, 2014 | Comments Off

Below are three tables that describe the exemptions and SEPs in the ACA. The first table enumerates the exemptions and the method by which an individual may claim them. The second table focuses specifically on one type of exemption pathway- hardships. This table lists several specific events that will qualify as a hardship exemption and how to claim them. The third table describes the SEPs, including the rationale behind them and who is affected.

Continue Reading »

Update: State Medicaid, Marketplace and Navigator Law Status

Posted on May 12, 2014 | Comments Off

This post provides the most updated map concerning state status on Medicaid expansion, Marketplace operation, and passage of Navigator laws.

Continue Reading »

RWJF and Urban report discusses repealing employer mandate

Posted on May 12, 2014 | Comments Off

A new report released by the Urban Institute and the Robert Wood Johnson Foundation stated that aside from costs, there would be a minimal impact if the administration removed the Affordable Care Act’s (ACA) employer mandate. The report, Why Not Just Eliminate the Employer Mandate?, stated that repealing the provision would result in 200,000 fewer individuals being covered in 2016, 500,000 fewer receiving employer-sponsored coverage, and 300,000 more qualifying for Medicaid or health insurance subsidies. Repealing the employer mandate, which the report states is not pivotal in expanding coverage under the ACA, would remove the business industry’s main issue with the ACA. The biggest challenge with removing the employer mandate would be finding a pay-for to account for the $130 billion the provision was anticipated to generate in fines and the costs of providing more subsidies.

Continue Reading »

New CMS rule reduces burden and promotes efficiency

Posted on May 8, 2014 | Comments Off

A final rule released by the Centers for Medicare and Medicaid Services (CMS) is designed to loosen policies that could save hospitals up to $3.2 billion over the next five years. One policy addressed removes the requirement that a physician must be present at a rural health center every two weeks, which was implemented to help combat the shortage of rural health providers. The rule also relaxes supervision requirements for some providers, such as dieticians. Easing regulations under this rule follows suit with the administration’s “regulatory lookback” that began in 2012.

Continue Reading »

Administration releases more ACA guidance

Posted on May 5, 2014 | Comments Off

Last Friday, the Centers for Medicare and Medicaid Services (CMS) posted a new bulletin on special enrollment periods and hardship exemptions under the Affordable Care Act (ACA). The bulletin provides information on how federally-facilitated Marketplaces (FFM) should address coverage for individuals that fall into the following four categories: hardship exemptions for individuals that obtained coverage effective May 1st, special enrollment periods for individuals eligible for or enrolled in COBRA, special enrollment periods for individuals whose plans are renewing outside of open enrollment, and special enrollment periods for AmeriCorps/VISTA/National Civilian Community Corps Members. The bulletin suggests that state-based Marketplaces (SBM) use these guidelines to help individuals that fall into these categories.

The administration also released a new FAQ set regarding ACA implementation. This FAQ, prepared jointly by the US Department of Treasury, the US Department of Health and Human Services, and the US Department of Labor, addresses questions concerning a myriad of health reform topics. Several of the issues addressed include updated Department of Labor Model Notices for COBRA, out-of-network and out-of-pocket charges, and Summaries of Benefits and Coverage (SBC).

Continue Reading »

CMS releases payment rules

Posted on May 1, 2014 | Comments Off

A final rule released on Tuesday indicates that federally qualified health centers (FQHCs) may receive a 32% payment boost under Medicare’s new payment system. Effective October 1st of this year, Medicare will pay FQHCs a per member per day fee of $158.85, which will be adjusted for geographic differences in healthcare costs. The Centers for Medicare and Medicaid Services (CMS) currently does not adjust payments for FQHC patients.

Another rule released by CMS discusses inpatient payment regulations for 2015. Per the Hospital Readmission Reduction Program, Medicare payments to physicians with poor readmission rates could be reduced by as much as 3%. Hospitals with poor performance regarding hospital acquired conditions may face an additional penalty.

Other payment rules released by CMS include skilled nursing facilities, rehabilitation facilities, and psychiatric facilities, which all call for payment increases of 2%, 2.2%, and 2.1% respectively.

Continue Reading »

Study finds large employers could save money under ACA by dropping benefits

Posted on May 1, 2014 | Comments Off

A report issued by S&P Capital IQ found that if publicly traded companies drop employer-sponsored insurance (ESI) benefits by 2020, they could save more than $700 billion by 2025. The report, released earlier today, said that these companies would save substantially by paying the Affordable Care Act’s (ACA’s) penalty rather than paying premium contributions and other costs associated with offering ESI. The authors postulate that once several notable companies elect to no longer offer ESI, many others will follow suit, leading to potentially 90% of major corporation employees receiving ACA Marketplace coverage by 2020.

Continue Reading »

Health Affairs study indicates plan cancellations not abnormal

Posted on April 24, 2014 | Comments Off

A new study published in Health Affairs this week says that some insurance plans cancelled under the Affordable Care Act (ACA) may have been cancelled regardless by policyholders. The study, Insurance Cancellations In Context: Stability Of Coverage In The Nongroup Market Prior To Health Reform, uses Census data to assess the individual insurance market prior to ACA implementation and reported three key findings:

  • There was high turnover in the market;
  • 80% of those in the market acquired another form of coverage within in the year, mainly from an employer; and
  • turnover varied among groups (age, employment status, etc.)

As a result, the study purports this market experienced disruption well before the implementation of the ACA’s insurance reforms.

Continue Reading »