Implementation Update

Update: Medicaid DSH Final Rule

Posted on October 8, 2013

On September 13th, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a final rule concerning the reduction of Medicaid Disproportionate Share Hospital (DSH) payments to hospitals. The reduction methodology discussed in this rule will be effective for FY 2014 and FY 2015…

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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…

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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.

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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…

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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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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…

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