Implementation Briefs

Update: Final 2015 Letter to Issuers in the Federally-Facilitated Marketplace: Access and Non-Discrimination Considerations

Posted on April 9, 2014

On March 14, 2014 the Centers for Medicare and Medicaid Services (CMS) published its 2015 letter to issuers selling qualified health plans in the federally facilitated Exchange Marketplace (FFM). The issuers letter is designed to provide federal guidance on the qualified health plan certification process to health insurance issuers and states that use the FFM while also maintaining plan management partnerships with the federal government (AL, AK, AZ, AR, DE, FL, GA, IL, IN, IA, KS, LA, ME, MI, MS, MO, MT, NE, NJ, NY, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WV, WI, WY). This Update reviews highlights of the final 2015 letter (we reviewed the draft letter in a prior Update.

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Insurance Affordability: Payment of premium and cost sharing payments made on behalf of enrollees by federal and state programs

Posted on April 2, 2014

Individuals purchasing qualified health plans and stand-alone dental plans (for the child component) through the Health Insurance Marketplace can qualify for premium subsidies and cost sharing reduction assistance if their modified adjusted gross incomes fall between 100% and 400% of the federal poverty level. Although as a matter of law the subsidies provided are deemed sufficient to make coverage affordable, for many individuals, the level of subsidy furnished is insufficient as a practical matter. Governmental programs such as the Ryan White Care Act and other federal and state programs may be available to help these individuals meet the cost of coverage by paying their share of premiums or assisting them with their portion of deductibles and other cost sharing. In recent weeks, however, news reports surfaced regarding the refusal by some insurers to accept payment made on behalf of enrollees.

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Update: Expanded Federal Regulation of Navigators and Other Consumer Assistance Personnel

Posted on March 26, 2014

Federal regulations establish standards governing Navigator and non-Navigator consumer assistance programs. Navigators and non-Navigator assistance personnel must meet federal standards as well as state licensing and certification standards. Our prior update reviewed proposed federal rules that would clarify the criteria the federal government will apply in determining whether a state licensure or certification standard is preempted by federal law. The proposed rules also set additional federal standards governing Navigators and other consumer assistance personnel. Comments are due 30 days from publication of the proposed rule, which was published in the federal register on March 21, 2014.

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Proposed Standards for Navigators and Consumer Assistance Counselors: Preemption of Certain State Navigator Regulatory Laws

Posted on March 19, 2014

On March 17, 2014, HHS released a proposed rule in public view form that addresses a variety of issues including Exchanges, Navigators and Non-Navigator consumer assistance personnel, and other matters. The rule will appear in the Federal Register on…

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Update: Basic Health Program Final Regulations

Posted on March 12, 2014

On March 7, 2014, the Centers for Medicare and Medicaid Services (CMS) published final regulations implementing the Affordable Care Act’s Basic Health Program (BHP) market option (PPACA §1331). On that date, CMS also published rules that set forth the BHP payment methodology and the data it will use to determine payments to states that establish certified BHP programs.

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CMS Bulletin on Retroactive Advance Payments of Premium Tax Credits and Cost Sharing Reductions in 2014 Due to Exceptional Circumstances

Posted on March 7, 2014

On February 27, 2014, CMS issued a Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the PTC and CSRs in 2014 Due to Exceptional Circumstances. Using its authority to establish special enrollment periods under the ACA, CMS created a mechanism for recognizing certain “exceptional circumstances” that arise when as a result of “technical issues in establishing automated eligibility and enrollment functionality,” Exchanges have experienced difficulties in making timely eligibility determinations and enrolling people during the initial open enrollment period.

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

Posted on March 5, 2014

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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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

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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Update: Proposed IRS Procedures for Tax-Exempt Hospitals to Correct and Disclose Failures to Meet Their Community Benefit Obligations Under the Internal Revenue Code

Posted on January 13, 2014

In order to be exempt from federal income taxes, nonprofit hospitals seeking such a designation under the Internal Revenue Code must provide a community benefit, a policy that has been in place since 1969 but that has gone essentially unenforced since its creation by the Nixon Administration. Government estimates of the value of nonprofit hospital tax-exemption placed the total national value at more than $12 billion in 2002, a figure that undoubtedly has grown over the past decade and that reflects both federal tax losses and losses resulting from the fact that most states and localities use federal law to determine exemption from state and local property, sales, and income taxes…

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Rating the Quality of Qualified Health Plans Sold in the Marketplace

Posted on January 7, 2014

On November 19, 2013, the Obama Administration published a Notice with comment that describes the overall Quality Rating System (QRS) framework for rating the quality of health plans (QHPs) sold in the health insurance Marketplace (another term for Exchanges). The purpose of the Notice is to solicit comments on the framework. Comments must be received by January 21, 2014. Comments are sought on both the proposed quality measures that QHP issuers would be expected to report, as well as on ways to preserve the integrity of QHP ratings and on areas for future measurement…

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