Office of Consumer Information and Insurance Oversight
Posted on January 9, 2014
According to a set of FAQ’s issued by the Center for Consumer Information and Insurance Oversight (CCIIO), insurers are now required to fully cover medications that help reduce the incidence of breast cancer among women at high risk. Examples of these medications include tamoxifen and raloxifene. The policy change, arising from recommendations by the US Preventive Services Task Force (USPSTF), was decided in September 2013 and goes into effect for plan years beginning on or after September 24th, 2014.
Posted on December 30, 2013
The US Department of Health and Human Services (HHS) has permitted individuals whose insurance plans were canceled under the Affordable Care Act (ACA) to qualify for a hardship exemption and not be subject to the individual mandate for 2014. Hardship exemptions were created for individuals that experienced “financial or domestic circumstances, including an unexpected natural or human-caused event, such that he or she had a significant, unexpected increase in essential expenses that prevented him or her from obtaining coverage under a qualified health plan,” and the new decision by HHS places individuals with canceled health plans under this classification. The policy change, announced both in a letter to several senators and through official guidance from the Centers for Medicare and Medicaid Services (CMS), requires individuals with canceled plans to submit a hardship exemption form and proof of plan cancellation. Individuals choosing to claim a hardship exemption may forgo insurance for 2014 without a penalty or choose to enroll into catastrophic plans, which are bare-bones plans typically reserved for individuals under the age of 30.
Posted on November 14, 2013
A letter written to state insurance commissioners from Gary Cohen, Direct of the Center for Consumer Information and Insurance Oversight (CCIIO), encouraged states to adopt a transitional policy concerning cancellation of health plans as a result of the Affordable Care Act (ACA). The letter states that active plans in the individual and small group markets may be renewed for the 2014 plan year if (1) the plan was in effect as of October 1st, 2013 and (2) the insurance issuer sends a letter to plan members that have or will have their plans terminated. The letter should describe:
- changes in available insurance options;
- how the plan member’s current plan deviates from the market reforms instituted by the ACA (i.e. no coverage of individuals with pre-existing conditions, no guaranteed issuance, etc.);
- the right and ability of a plan member to enroll in a plan through the ACA’s health insurance marketplaces;
- how a plan member may enroll in a new plan through the ACA marketplaces; and
- the ability of the plan member to enroll in another plan outside of the marketplaces that adheres to ACA market reforms.
Posted on October 29, 2013
The Center for Consumer Information and Insurance Oversight (CCIIO), within the Centers for Medicare and Medicaid Services (CMS), published an FAQ concerning the open enrollment period for individuals purchasing qualified health plans (QHPs) under the Affordable Care Act (ACA). The guidance states that individuals will be able to enroll in QHPs throughout the entire enrollment period, which lasts through March 31st, and not be subject to the individual shared responsibility payment. According to the ACA, individuals would have to enroll in a plan by the 15th of each month in order for their QHP coverage to be effective at the start of the following month. Individuals that enrolled in plans after the 15th would not be covered for another two months. The issue pertains to individuals that would enroll in QHPs between February 16th and February 28th of 2014. These individuals would not be covered until April 1st, and would therefore be subject to the minimum essential coverage penalty under the ACA (the minimum essential coverage provision states that an individual must pay a penalty if he or she does not have coverage for more than three consecutive months in a year). This guidance removes that snafu in the law and states that CCIIO will provide additional guidance on the issue in 2014.
Posted on August 28, 2013
The Centers for Medicare and Medicaid Services (CMS) released a final rule today implementing a multitude of provisions within the Affordable Care Act (ACA). The final rule, which has remained largely unchanged from the program integrity proposed rule published in June, provides policies designed to protect consumer information and ensure appropriate usage of federal funds. Specifically, the rule requires oversight of qualified health plan (QHP) issuers on federally-facilitated Marketplaces and oversight of privacy and security measures instituted on state-based Marketplaces. The rule also covers eligibility appeals for the individual and small business health options program (SHOP) markets.
The Center for Consumer Information and Insurance Oversight (CCIIO) within CMS concurrently released a fact sheet that outlines the key provisions discusses in the final rule.
Posted on July 8, 2013
Technical guidance released by the Center for Consumer Information and Insurance Oversight (CCIIO) clarifies how insurers should address fees related to the Affordable Care Act (ACA) when they are tabulating their medical loss ratio (MLR) and the associated rebates. The ACA mandates that large-group insurers must spend 85% of their premium revenue on healthcare expenditures for their insureds (80% for individual and small-group insurers). CCIIO’s new guidance states that insurers may exclude ACA-related fees from MLR calculations for a reporting year if the fees were incurred during that same reporting year. Insurers may not exclude fees they anticipate to incur in future MLR reporting years.
Posted on June 28, 2013
A compilation of documents released by the Center for Consumer Information and Insurance Oversight (CCIIO) addresses the meaningful difference requirement of qualified health plans (QHP) to be offered on health insurance Exchanges. To promote simplified, informed consumer choice, the Affordable Care Act (ACA) requires QHPs from a single issuer to be meaningfully different from one another. The following documents have been released by CCIIO to expand upon the meaningful difference requirement:
- QHP FAQ #7 addresses the issue of offering QHPs with the same benefits and cost sharing, but vary only in the network (Q 32).
- QHP FAQ #9 provides the definition of meaningful difference (Q 26).
- QHP FAQ #10 discusses the number of QHPs an issuer may submit for a federally-facilitated exchange (FFE) to be approved (Q 20).
- Instructions for QHP submission contains a chapter discussing suggested formats for justification that issuers may submit as part of the QHP application process, including a specific justification and documentation form.
Posted on June 20, 2013
Guidance recently released by the Centers for Medicare and Medicaid Services (CMS) provides information on how state based Exchanges (SBE) can design applications to determine a constituent’s eligibility for qualified health plans (QHP) and insurance affordability programs, such as Medicaid. The guidance states that any SBE may elect to use the federally-facilitated Exchange (FFE) model application released by CMS in late April. If an SBE decides to develop their own eligibility application, the application is expected to be a streamlined, singular document commensurate to the FFE version, and it must be approved by CMS.
Posted on May 17, 2013
The Center for Consumer Information and Insurance Oversight (CCIIO) issued additional information on navigators and other consumer assistance and outreach programs provided by the Affordable Care Act (ACA). The document expands upon the standards with which these assistors must comply, available grant funding, and the differences between the assistance programs.
Posted on May 17, 2013
The Center for Consumer Information and Insurance Oversight (CCIIO), a division of the Centers for Medicare and Medicaid Services (CMS), recently posted new guidance concerning federally-facilitated and state-based Exchanges (Marketplaces) established under the Affordable Care Act (ACA). The guidance purports that if states do not adhere to and enforce the requisite standards for health insurance issuers in federally-facilitated Exchanges, then CMS intends to coerce enforcement through civil penalties and plan decertification. CMS does not believe that decertification will be a common occurrence. In addition, the guidance stated that qualified health plans (QHP) paired with health savings accounts (HSA) must meet the cost-sharing reduction standards that apply to low income-individuals.
CCIIO published additional guidance that expands upon which activities, in both federally-facilitated and state-based Marketplaces, that qualify for grant funding under ACA Section 1311. For instance, state-based Marketplaces are not permitted to use this funding for navigator outreach and education, yet they are allowed to use Section 1311 funds for “in-person assistance programs.”