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

Centers for Medicare & Medicaid Services

CMS issues Basic Health Program information for 2016

Posted on October 22, 2014

The Centers for Medicare and Medicaid Services (CMS) issued a proposed notice on how the federal government will determine payment amounts for 2016 for states that decide to establish a Basic Health Program. The Basic Health Program is a voluntary option under the Affordable Care Act (ACA), which provides insurance to individuals between 133 and 200 percent of poverty through a separate program rather than having them go to the exchanges. The proposed notice says that states that establish the program will receive federal funding equal to 95 percent of the amount of premium tax credits and cost-sharing subsidies that would have otherwise been provided to those individuals for exchange plans. However, the funding does not cover states’ ongoing administrative or operational costs.

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CMS issues guidance on ACA health insurance tax

Posted on October 9, 2014

Guidance issued by the Centers for Medicare and Medicaid Services (CMS) advises states that that their capitated payment rates for Medicaid managed care plans should cover the costs of the Affordable Care Act’s (ACA) health insurance tax, as it is considered a “reasonable business cost.” The tax starts at $8 billion in 2014 and increases every year, up to $14.3 billion in 2018. Starting in 2019, the amount of the tax will increase annually based on premium trends. CMS contends that this fee is not unlike other taxes and fees that actuaries must take into account when developing capitation rates.

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CMS approves PA Medicaid waiver

Posted on August 29, 2014

The Centers for Medicare and Medicaid Services (CMS) approved Pennsylvania’s waiver application to receive matching funds under the Affordable Care Act (ACA) for extending Medicaid eligibility to residents who earn up to 133 percent of the federal poverty level.  Although substantially revised from the original proposal, the approved waiver creates a five-year Medicaid demonstration, entitled “Healthy Pennsylvania.”  Starting in January, as many as 600,000 Pennsylvanians could be eligible for new coverage on the private market, according to Pennsylvania Governor Tom Corbett’s office..

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CMS announces updated training program for ACA navigators

Posted on August 15, 2014

The Centers for Medicare and Medicaid Services (CMS) released a bulletin 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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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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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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HHS releases final Marketplace rule

Posted on May 16, 2014

The US Department of Health and Human Services (HHS) issued a final rule entitled Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond. Some specific provisions in the rule include:

  • Raising the administrative costs and profits ceiling under the risk corridor formula by 2%.
  • Providing information on how to include ICD-10 costs under the medical loss ratio (MLR).
  • Requiring qualified health plans (QHP) on the ACA Marketplace to have a more efficient and effective method for enrollees to acquire medications not covered on the plan. This specifically applies to enrollees on a course of treatment in which absence of the medication would substantially impact the individual’s life and health.
  • Requiring insurers to annually report plan changes to beneficiaries.
  • Beginning in 2016, Marketplaces will have to display quality data on all plans for public viewing. The data will be based on a five-star system and enrollee satisfaction surveys.
  • Enumerating state requirements that may prohibit Navigators or other assistors from performing their roles. For example, Navigators may go door-to-door for enrollment assistance and outreach. They may not, however, provide gifts to entice enrollment.
  • Delaying the “employee choice” option in the small business health options program (SHOP) to 2016.

The final rule is largely unchanged from the proposed version. An FAQ addressing market reforms and Marketplace standards can also be accessed here.

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