Implementation Update
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…
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…
Update: Using Medicaid to Provide Premium Assistance for Exchange Coverage
Posted on April 10, 2013
This update to our previous Implementation Brief on states’ option to implement Medicaid coverage by enrolling beneficiaries into Qualified Health Plans sold in Exchanges examines Frequently Answered Questions on Medicaid and Premium Assistance (“FAQ”), released on March 29th by CMS. The FAQ answer some, but not all, questions raised by this approach to implementation of the ACA Medicaid expansion…
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Multi-State Health Plans: The Final Rule
Posted on April 3, 2013
The state health insurance exchanges are designed to provide consumers choices among pre-approved health plans that meet certain federal standards ranging from the provision of specific benefits to anti-discriminatory requirements for pre-existing health conditions. Only plans that meet these standards – the qualified health plans, or QHPs – will be allowed to participate in the exchanges. To further foster competition, the ACA also requires two QHPs participating in each exchange to be multi–state plans…
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The QHP Certification Process in Federally-Facilitated Exchanges: Network Adequacy and Essential Community Providers
Posted on March 27, 2013
One of the more complex Affordable Care Act implementation questions involves the relationship between health insurance Exchanges and state departments of insurance around the issue of qualified health plan (QHP) certification. This relationship is discussed at some length in federal guidance published on March 1 2013, which offers the federal government’s latest thinking on how this relationship might work in states in which a federally funded Exchange (FFE) is operating, either with or without a Partnership agreement. As of March 2013, an FFE is expected to be operating in…
Update: Contraception Coverage within Required Preventive Services
Posted on March 20, 2013
The ACA requires all individual and non-grandfathered group health plans to cover certain preventive services, including contraceptive services. This is an update to the March 2012 brief on Contraception Coverage within Required Preventive Services, and to the April 2012 update to that brief.
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Update: Essential Health Benefits Final Rule
Posted on March 13, 2013
On February 25th, 2013, final regulations implementing the essential health benefit (EHB) provisions of the Affordable Care Act were published in the Federal Register (78 Fed. Reg. 12834-12872). The EHB rules, which amend 45 C.F.R., apply to all non-grandfathered individual and small group health plans sold after January 1, 2014, as well as Medicaid benchmark and benchmark-equivalent health plans. The EHB rules also apply to…
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Most Popular Content
- State Health Insurance Exchange Navigators posted on February 28, 2011
- The QHP Certification Process in Federally-Facilitated Exchanges: Network Adequacy and Essential Community Providers posted on March 27, 2013
- Reform Overview posted on April 12, 2010
- Summary of the U.S. Supreme Court decision in the case of National Federation of Independent Businesses et al. v. Sebelius, Secretary of Health and Human Services, et al. posted on June 28, 2012
- Navigators and Application Counseling and Assistance posted on April 24, 2013
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- Update: Frequently Asked Questions on Patient Cost-Sharing Under the ACA – Set 12
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