Implementation Briefs
Medicare and Medicaid Disproportionate Share Hospital Payments: Proposed Rules
Posted on June 13, 2013
For thirty years, the Medicare and Medicaid programs have furnished additional payments to hospitals that furnish a disproportionate share of services to low income populations. Despite the fact that the two disproportionate share hospital (DSH) programs share a common mission, they function differently in terms of how the funds actually move to hospitals and in the formulas used to make DSH payments. The Affordable Care Act makes significant adjustments in both DSH programs beginning in 2014 in anticipation of a significant expansion in the proportion of people who have health insurance coverage. With the United States Supreme Court’s decision in 2012 in NFIB v Sebelius, which permits states to opt out of the Medicaid expansion without risking the loss of federal funding for their existing Medicaid programs, the downward DSH payment adjustments become an even more significant matter for hospitals that treat large volumes of low income patients…
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Explaining Recent Changes in CBO Projections of Health Insurance Coverage and Costs under the Affordable Care Act
Posted on June 5, 2013
In May 2013, the Congressional Budget Office (CBO) issued its latest update of estimates of health insurance coverage and costs under the Affordable Care Act. This Implementation Brief summarizes the changes in CBO’s estimates over time, focusing on three key sets of estimates…
Health Information Implications of the 2014 HHS Budget
Posted on May 29, 2013
On April 10, 2013, President Obama released his proposed FY 2014 budget, which includes $967.3 billion in outlays for the Department of Health and Human Services (HHS) and makes legislative proposals that would save an estimated $361.1 billion (net) over ten years. In conjunction with the release of the President’s budget, HHS published an overview of the budget provisions for HHS, which provides more detail on how the Department would allocate its budget in FY 2014 and describes its ongoing progress in meeting specific program goals and legislative requirements. Many of the proposals included in the President’s budget and HHS’ overview relate to the ongoing transformation of the health care delivery system to a value-based system that rewards quality and efficiency. Critical to the success of this transformation is the exchange of health information for activities such as quality measurement and reporting, value-based purchasing, consumer engagement, and comparative effectiveness research. Below are selected provisions of the HHS budget, the agency’s relevant legislative proposals for 2014, and progress reports for health care system reform efforts that require the use and exchange of health information. We also identify HHS’ stated priorities for 2014 that are related to health information…
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CMS State Resources FAQ: Medicaid Eligibility Determinations, Medicaid/Exchange Interactions, and §1115 Demonstrations that Use Enrollment Caps
Posted on May 22, 2013
The interaction between Medicaid and Exchanges around eligibility determination issues represents one of the most important and complex aspects of the ACA. An estimated 28 million adults, along with 19 million children, can be expected to transition at least once annually between insurance affordability programs, as Medicaid and premium subsidies are termed under implementing CMS regulations. Collaboration between Medicaid agencies and Exchanges is essential in order to avert unnecessary delays in eligibility determinations and breaks in coverage that in turn can affect not only the affordability of care but access itself, given the link between coverage and health care access through plans’ provider networks…
Update: Frequently Asked Questions on Patient Cost-Sharing Under the ACA – Set 12
Posted on May 16, 2013
The ACA contains numerous provisions affecting patient cost-sharing, both generally and in relation to specific services. Some of the provisions (such as those related to preventive services and annual limits on out-of-pocket cost-sharing) apply across multiple coverage markets (i.e., to health insurance products sold in both the individual and group markets as well as to self-insured plans). Other provisions, such as those governing deductibles applicable to the essential health benefit (EHB) package, apply only to those markets that are subject to the EHB requirement, i.e., health plans sold in the individual and small group (under 100 full-time employees) market. In general, the cost-sharing rules exempt grandfathered health plans.
Final Rule: Notice of Benefit and Payment Parameters for 2014
Posted on May 8, 2013
On March 11, 2013, the U.S. Department of Health and Human Services (HHS) released a final rule on the Notice of Benefit and Payment Parameters for 2014. This final rule addresses a variety of issues, including the specific payment parameters for the three premium stabilization programs – the permanent risk adjustment program, the transitional reinsurance program, and the temporary risk corridors program. In addition, the final rule also covers advance payments of the premium tax credit, cost-sharing reductions, and user fees for the federally-facilitated Exchanges, specific requirements related to the federally facilitated Small Business Health Option Program (SHOP), and the medical loss ratio program. This rule finalizes the provisions set forth in HHS’s proposed rule on these topics, December 7, 2012…
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Interim Final Rule: Alternative Approaches to Cost-Sharing Reduction Payment and Risk Corridor Calculations
Posted on May 8, 2013
The temporary risk corridors program allows the federal government to share a QHP’s profits or losses among other QHP issuers due to inaccurate rate setting inside the Exchanges from 2014-2016. To determine whether a QHP issuer has inaccurately set premium rates that lead to an unjustified profit or loss, a QHP’s “allowable costs” must be calculated per the requirements in the Premium Stabilization Rule. The IFR modifies the definition of “allowable costs” such that a QHP’s allowable costs are to be determined based on its pro-rata share of the QHP issuer’s incurred claims for all non-grandfathered health plans within a state, and allocated to the QHP based on premiums earned by the issuer in the market…
Sub-Regulatory Guidance Regarding Age Curves, Geographical Rating Areas and State Reporting
Posted on May 1, 2013
This Age Curve portion of the sub-regulatory guidance reminds states that in the absence of a state-established and HHS-approved uniform age rating curve for the purpose of age rating in the individual and small group markets, a federal default standard will apply. The statute and final rule require that the premium rate charged by an issuer in the individual and small group market (for non-grandfathered plans) may vary by age, but not by more than a 3:1 ratio for adults. Moreover, the final rule defines, and the sub-regulatory guidance reiterates, the standard age bands for insurance rating purposes as follows…
Navigators and Application Counseling and Assistance
Posted on April 24, 2013
The ACA (§§1311(d) and (i)) and implementing regulations (45 C.F.R. §155.210) require that all Exchanges establish Navigator programs to provide fair, accurate and impartial information regarding health insurance coverage across Exchanges and state Medicaid and CHIP programs. Navigators also facilitate selection of QHPs and provide referrals for consumers with questions, complaints, or grievances to other consumer assistance and ombudsman programs. The Navigator program requirement applies regardless of whether the Exchange is operated by a state government or by the federal government (known as a “federally-facilitated Exchange”), either with or without a state Consumer Assistance Partnership…
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Update: Treasury/IRS Proposed Rule on Community Benefit Obligations of Nonprofit Hospitals
Posted on April 17, 2013
Prior to 1969, nonprofit hospitals, as a condition of their tax-exempt status, were expected to furnish uncompensated care to persons unable to pay. In 1969, the Nixon Administration broadened this obligation to encompass “community benefits,” which could take the form of not only free or reduced-cost care, but also other activities that hospitals determined would benefit their communities, such as health promotion activities, research, and education and training. This more amorphous concept of community benefit went unenforced for decades. However, following years of government reports and news stories focusing on the limited level of uncompensated care furnished by many nonprofit hospitals, as well as the imposition of excessive charges and use of harsh billing practices on the uninsured, Congress moved to address the issue…
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- State Health Insurance Exchange Navigators posted on February 28, 2011
- CMS State Resources FAQ: Medicaid Eligibility Determinations, Medicaid/Exchange Interactions, and §1115 Demonstrations that Use Enrollment Caps posted on May 22, 2013
- Reform Overview posted on April 12, 2010
- The QHP Certification Process in Federally-Facilitated Exchanges: Network Adequacy and Essential Community Providers posted on March 27, 2013
- Update: Essential Health Benefits Final Rule posted on March 13, 2013
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Recent Posts
- Urban Institute examines state roles in FFE
- GWU researchers assess hospital community benefit expenditures
- Medicare and Medicaid Disproportionate Share Hospital Payments: Proposed Rules
- CRS report explains ACA premium tax credits
- Interview of Phyllis Borzi, Assistant Secretary of Labor of the Employee Benefits Security Administration (EBSA), United States Department of Labor
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