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Department of Health and Human Services

CMS announces updated training program for ACA navigators

Posted on August 15, 2014

The Centers for Medicare and Medicaid Services (CMS) is updating the Navigator, non-Navigator assistance personnel, and certified application counselor training curriculum for the Federally-facilitated and State Partnership Marketplaces in preparation for the next Open Enrollment Period beginning November 15, 2014.  The expanded curriculum will include more information on immigration, household income calculations and help for specific populations, including victims of domestic abuse and college students.  All assisters, whether they are seeking recertification or initial certification, will be required to complete the new training program.

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CMS publishes Medicare pay final rule

Posted on August 5, 2014

The Centers for Medicare and Medicaid Services (CMS) issued a final rule revising the Medicare hospital inpatient prospective payment systems (IPPS). In adherence to the Affordable Care Act (ACA), part of the rule would effectively reduce payments to disproportionate share hospitals (DSH), which serve the most vulnerable patients. DSH payment reductions are a result of the expansion of Medicaid, however in states that chose not to expand, hospitals still risk losing some payment for uncompensated care.

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CMS issues regulations on premium payment

Posted on July 24, 2014

The Center for Consumer Information and Insurance Oversight (CCIIO) and the Centers for Medicare & Medicaid Services (CMS) issued Federal guidance which gives individuals a three-month grace period to pay a premium without losing coverage. However, the same guidance states that if individuals choose enroll in a new policy for 2015, insurance companies cannot apply new premiums to outstanding 2014 debt. Some have suggested that this inconsistency could allow consumers to avoid paying their December premiums. However, nothing bars an insurer from making a bona fide effort to collect any unpaid premiums, as the consumer would still owe this amount to the insurer.

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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.

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Study finds an increase in premiums in 2013

Posted on July 17, 2014

The Agency for Healthcare Research and Quality’s (AHRQ) Medical Expenditure Panel Survey reports that premiums for employer-sponsored insurance increased by about 3.5 percent in 2013. Out-of-pocket costs also climbed by at least 4 percent in 2013. However, the majority of Affordable Care Act (ACA) insurance market reforms did not take effect until 2014, meaning data on 2014 premiums will provide more meaningful insight into the law’s impact on premiums and cost sharing.

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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.

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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:

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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.

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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.

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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.

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