A project of the George Washington University's Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation

Key Developments

IRS releases employer mandate draft forms

Posted on July 25, 2014

The Internal Revenue Services (IRS) released two draft forms for employers required to adhere to the employer shared responsibility payment, or employer mandate, under the Affordable Care Act (ACA).  Beginning in 2015, employers with 100 or more employees will be required to provide health insurance to their employees pursuant to the ACA, and employers with more than 50 employees will be expected to comply with the mandate beginning in 2016.  The new draft forms are currently available for comment.

Continue Reading "IRS releases employer mandate draft forms" »

HRSA removes orphan drug exemption under 340B

Posted on July 22, 2014

A rule released yesterday by the Health Resources and Services Administration (HRSA) clarifies a portion of the 340B program, which requires drug manufacturers to offer their pharmaceuticals at a discounted rate to covered entities.  Under 340B, a covered entity typically refers to healthcare providers treating medically vulnerable populations, such as Ryan White Clinics or Disproportionate Share Hospitals.  The new rule specifically removes the discount exemption for orphan drugs sold for off-label usage.  A recent lawsuit led to the promulgation of this interpretative rule,  as many orphan drugs are used to treat conditions other than the rare conditions for which the drugs were created.

Continue Reading "HRSA removes orphan drug exemption under 340B" »

CMS releases 2015 Medicare payment rules

Posted on July 4, 2014

The Centers for Medicare and Medicaid Services (CMS) issued several rules concerning Medicare payments for 2015.  First, CMS released the 2015 physician fee schedule.  Pursuant to the “doc fix” legislation recently passed, this proposal holds physician payments for the first quarter of next year.  The rule also bolsters the Physician Payment Sunshine Act by requiring providers to report payments received from speaking at continuous education events.  Additionally, the proposal revises the quality scoring methodology so that accountable care organizations (ACOs) are better able to exemplify the improvements they make in quality measures.  The number of metrics will increase from 33 to 37.

Yesterday, CMS also updated the payment scheme for outpatient services by 2.1% for 2015.  Biologics and non-pass-through drugs are still expected to be paid at average sales price plus 6%.  Payments are anticipated to increase by $5.2 billion compared to 2014.

Continue Reading "CMS releases 2015 Medicare payment rules" »

CMS releases proposed rule on annual eligibility determinations

Posted on June 26, 2014

A new proposed rule issued today by the Center for Consumer Information and Insurance Oversight (CCIIO) discussed annual eligibility redetermination under the Affordable Care Act (ACA) and several other enrollment standards for ACA Marketplace. CCIIO stated that nearly all of those currently enrolled in an ACA Marketplace plan will be re-enrolled unless they choose a new plan in the next open enrollment period or the plan in which they are currently enrolled is terminated. The rule proposes three methods for ACA Marketplaces to conduct annual redeterminations for enrollment. The rule also proposes standards to redetermine eligibility within a plan year and when an individual’s plan in the ACA Marketplace is not available for re-enrollment for the next plan year.

Additional guidance includes:

Continue Reading "CMS releases proposed rule on annual eligibility determinations" »

Rule finalizes 90-day waiting limit

Posted on June 20, 2014

Today, the US Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA) released a final rule concerning the 90-day waiting period limitation. The final rule states that group health insurance plans cannot apply a waiting period that exceeds 90 days after the employee has been approved for coverage. The rule further states that small group plan orientation periods, the time it takes from hire to when the plan deems the employee is eligible for coverage, cannot exceed one month.

Continue Reading "Rule finalizes 90-day waiting limit" »

ASPE report indicates premium variation among states

Posted on June 18, 2014

A new report by the US Department of Health and Human Services (HHS) describes how premiums vary among the 36 states operating federally-facilitated Marketplaces under the Affordable Care Act (ACA). The report, released by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) within HHS, found the average premium payment by an individual receiving subsidies to be $82, with the subsidized average for the silver plan metal tier being $69. Average subsidized premiums ranged from $23/month in Mississippi to $148/month in New Jersey. The report does not capture the corresponding data for the state-based Marketplaces.

Continue Reading "ASPE report indicates premium variation among states" »

CMS rule sets payment adjustments for low-volume hospitals

Posted on June 13, 2014

The Centers for Medicare and Medicaid Services (CMS) issued a rule to change the payment adjustment for low-volume hospitals and Medicare-dependent hospitals. The changes would be issued under the hospital inpatient prospective payment systems (IPPS) for the second half of fiscal-year 2014. According to the rule, a hospital is considered low-volume if it is more than 15 miles from another hospital and has less than 1600 discharges of individuals entitled to or enrolled in Medicare Part A.

Continue Reading "CMS rule sets payment adjustments for low-volume hospitals" »

CCIIO issues FAQ on ECPs

Posted on June 12, 2014

A new FAQ released by the Center for Consumer Information and Insurance Oversight (CCIIO) addresses questions insurance issuers may have concerning Essential Community Providers (ECPs). The Affordable Care Act (ACA) requires issuers to contract with a sufficient number of ECPs, or providers that generally treat low-income and medically underserved patients. The FAQ describes specifics of the ECP requirements, how issuers can access the non-exhaustive ECP list, and how ECPs can actively pursue inclusion in insurance planes. A similar FAQ addressing the same ECP issues was released in May of 2013.

Continue Reading "CCIIO issues FAQ on ECPs" »

IRS Q&A clarifies employer payment plans

Posted on May 27, 2014

According to a Q&A document recently released by the Internal Revenue Service (IRS), employers that do not offer health insurance but reimburse premiums for employees that purchase private insurance may be hit with a financial penalty. The Q&A states that employers utilizing this approach are effectively creating employer payment plans, which are beholden to the same rules and requirements as other group health plans under the Affordable Care Act (ACA). The IRS states that this arrangement does not comply with the ACA market reforms, and offering this option to employees may result in a $100/day excise tax per applicable employee for the employer.

Continue Reading "IRS Q&A clarifies employer payment plans" »

CMS issues Medicare Advantage and Part D final rule for 2015

Posted on May 21, 2014

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 "CMS issues Medicare Advantage and Part D final rule for 2015" »