Centers for Medicare & Medicaid Services

HHS issues NPRM on CO-OP plans

Posted on July 18, 2011

The U.S. Department of Health and Human Services (HHS) has issued a notice of proposed rulemaking (NPRM) on the Consumer Operated and Oriented Plan (CO-OP) program. Established by the Affordable Care Act (ACA), the CO-OP program allows private, non-profit insurance plans to be offered through the Exchanges as an alternative for consumers to traditional, for-profit plans. CO-OP plans are consumer-run, and accountable to their individual membership in a way that most traditional for-profit health plans typically are not.

For more information on the CO-OP program, click here.

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HHS releases risk adjustment rule, long-awaited exchange rule

Posted on July 12, 2011

The U.S. Department of Health and Human Services (HHS) has released a proposed rule on the American Health Benefit Exchanges under the Affordable Care Act (ACA). The proposed rule addresses standards for establishing exchanges, setting up the small business SHOP exchanges, and certifying plans for participation in Exchanges. HHS also release a proposed rule on risk adjustment and reinsurance. This proposed rule implements standards for States related to reinsurance and risk adjustment, and for health insurance issuers related to reinsurance, risk corridors, and risk adjustment, as required by the ACA.

More detailed analyses on these individual rules will be forthcoming on HealthReformGPS.org

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HHS announces new initiatives to improve care for duals

Posted on July 11, 2011

The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health of Health and Human Services (HHS) has announced a new round of initiatives to help improve quality and cost of care for individuals who are eligible for both Medicare and Medicaid. CMS has issued three fact sheets, along with preliminary guidance in the form of a State Medicaid Director Letter (SMDL), further outlining these initiatives. They involve upcoming demonstrations on new financial models for improved care coordination, efforts to improve nursing home care quality, and information on a new technical assistance resource center that will help states better serve high-cost, high-need beneficiaries.

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Release of Medicare Data for Performance Measurement

Posted on July 6, 2011

Health policy experts and lawmakers believe that measuring and publicly reporting information about the performance of physicians, hospitals, and other health care providers is critical to improving health care quality and controlling costs. Advancing health information access and transparency is a goal of the Patient Protection and Affordable Care Act (ACA), which includes a number of provisions to incentivize quality measurement and reporting and to enable more informed consumer decision-making.

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The Basic Health Program

Posted on June 29, 2011

An important issue in implementing the Affordable Care Act (ACA) is how to address the needs of uninsured low-income individuals and families whose incomes exceed Medicaid eligibility levels but are less than twice the federal poverty level (about $37,000 for a family of 3 in 2011). Under the ACA, the basic approach to assisting such individuals and families is the state health insurance Exchange, which enables qualified individuals to secure coverage and provides access to premium assistance and cost-sharing subsidies aimed at making coverage and care affordable.

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DOL/IRS issue amendments to IFR on claims appeals

Posted on June 22, 2011

The US Department of Labor (DOL) and the Internal Revenue Service (IRS) have issued separate amendments to the July 23, 2010 Interim Final Rule (IFR) on internal claims and appeals and external review processes for group health plans and health insurance issuers offering coverage in the group and individual markets. The Employee Benefits Security Administration (EBSA) of the Department of Labor has also issued new guidance on the subject.

The IFR, recent amendments, and recent guidance do not apply to grandfathered plans.

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CMS issues health IT guidance on state exchanges

Posted on June 6, 2011

The Centers for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services has issued an updated guidance to assist states as they design, develop, and implement health IT systems for health insurance exchanges mandated under the Affordable Care Act (ACA). The guidance addresses significant structural and business architecural components of the exchange framework, and is designed to promote a “high quality customer experience.”

One highlight of the guidance is a description of the “data services hub” that CMS plans to establish and is designed to help states verify citizenship, immigration status, and income of applicants for health plans offered on the exchanges. Under the ACA, the American Health Benefits Exchanges must be up and running by January 1, 2014.

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CMS issues final rule on barring Medicaid match for certain medical conditions

Posted on June 6, 2011

The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) has issued a final rule restricting federal Medicaid match funding for payments to providers whose patients have certain preventable medical conditions. The rule is intended to “better align Medicare and Medicaid payment policies,” CMS said in a press release accompanying the rule. The rule implements Section 2702 of the Affordable Care Act (ACA), which requires the Secretary to adjust federal Medicaid payments for health care-acquired conditions (HCACs), similar to what is done in the Medicare program. The final rule extends the effective date by one year, from July 1, 2011 to July 2, 2012.

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HHS releases plan for retrospective rule review

Posted on May 26, 2011

The US Department of Health and Human Services (HHS) has issued a new plan aimed at improving the agency’s rulemaking and regulatory process. Pursuant to President Obama’s Executive Order 13563 of January 18, 2011, and its intent to make the nation’s overall regulatory process more transparent and less cumbersome, the HHS plan sets forth the agency’s priorities for reviewing, streamlining, and if necessary, removing existing rules and regulations.

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CMS issues final rule on insurance rate review

Posted on May 20, 2011

The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) have issued a final rule implementing Section 1003 of the Affordable Care Act (ACA), which governs disclosure and review of “unreasonable” health insurance premium rate increases. As with the previously-issued proposed rule, the final rule calls for justification by insurers to state or federal reviewers on any health insurance premium rate increase of 10% or more, beginning in September of 2011. After one year, in September 2012, the level triggering state or federal rate review and justification will be 10%, or at a state-determined level based on individual factors within that state.

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