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Centers for Medicare & Medicaid Services

CMS FAQ discusses risk corridor

Posted on April 12, 2014

A new set of Frequently Asked Questions (FAQs) issued by the Centers for Medicare and Medicaid Services (CMS) answers several questions concerning the risk corridor provision of the Affordable Care Act (ACA). Pursuant to the Notice of Benefit and Payment Parameters for 2015 final rule, CMS stated that the risk corridor provisions would be implemented in a budget neutral manner. The new FAQ stated how the administration will address various issues that may arise in providing risk corridor payments, including sufficiency and medical loss ratio (MLR) determinations.

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Update: Final 2015 Letter to Issuers in the Federally-Facilitated Marketplace: Access and Non-Discrimination Considerations

Posted on April 9, 2014

On March 14, 2014 the Centers for Medicare and Medicaid Services (CMS) published its 2015 letter to issuers selling qualified health plans in the federally facilitated Exchange Marketplace (FFM). The issuers letter is designed to provide federal guidance on the qualified health plan certification process to health insurance issuers and states that use the FFM while also maintaining plan management partnerships with the federal government (AL, AK, AZ, AR, DE, FL, GA, IL, IN, IA, KS, LA, ME, MI, MS, MO, MT, NE, NJ, NY, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WV, WI, WY). This Update reviews highlights of the final 2015 letter (we reviewed the draft letter in a prior Update.

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Administration releases a deluge of ACA rules

Posted on March 17, 2014

The administration recently issued several rules and guidance concerning the implementation of the Affordable Care Act (ACA). Below are key points from some of these new releases:

  • A new Frequently Asked Question (FAQ) document from the Centers for Medicare and Medicaid Services (CMS) states that most insurance plans will be required provide the same benefits to married gay couples as they do to heterosexual married couples. Insurance companies will extend these nondiscrimination policies to same sex couples for plans offered on the ACA marketplaces.
  • An interim final rule released by CMS requires plans offered through the ACA marketplaces to accept premium and cost-sharing payments from certain federal government programs. Such programs include the Ryan White HIV/AIDS program and various Indian organizations.
  • CMS also released the proposed rule concerning market standards for 2015. The rule covers a multitude of topics, ranging from new standards for self-funded non-federal plans opting out of certain Public Health Service Act (PHSA) requirements to amending guaranteed renewability stipulations.
    • One particular provision of this rule was designed to preempt state laws created to increase the certification requirements and restrict the roles of navigators and other assistors under the ACA. Additionally, the rule prohibits assistors from performing certain activities that received substantial criticism, such as cold calling potential consumers or offering cash incentives to promote enrollment. The rule also provides some leeway for insurers under the medical loss ratio (MLR) requirements as a result of the stymied roll out of the federal health insurance marketplace.
    • Another interesting provision in the rule will require insurers to provider a more robust network of doctors and hospitals for consumers. Many plans offer “narrow networks” as a mechanism to cut costs for consumers, yet many consumers are losing coverage for their family practitioners. CMS will determine whether or not the plans provide “reasonable access” to certain services, such as mental health, oncology, and primary care.
    • In addition to the rule, CMS also provided guidance regarding discontinuing or renewing policies in the group or individual markets.

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CMS releases 2015 final letter to issuer

Posted on March 14, 2014

Today, the Centers for Medicare and Medicaid Services (CMS) released the finalized version of the 2015 Letter to Issuers in the Federally-facilitated Marketplaces. The letter provides technical and operational guidance to help qualified health plans (QHP) and stand-alone dental plans successfully participate in the Affordable Care Act (ACA) Marketplaces operated by the federal government.

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CCIIO issues Marketplace Blueprint

Posted on March 14, 2014

The Center for Consumer Information and Insurance Oversight (CCIIO) issued their Blueprint for Approval of Affordable Health Insurance Marketplaces. This document outlines key steps for states interested in altering their Marketplace configuration for 2015. The blueprint requires states to provide a letter of intent to CCIIO by May 1st and to submit their own Marketplace blueprints by June 1st. The blueprint also reminds states that Marketplace establishment grants will still be available to them through 2015.

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CMS releases BHP final rule

Posted on March 7, 2014

The Centers for Medicare and Medicaid Services (CMS) released a final rule and payment notice for the Basic Health Program (BHP). Under the Affordable Care Act (ACA), many individuals will have an income too high to qualify for Medicaid, yet subsidies may not make their health insurance affordable. BHP, a program aiming to reduce churning between Medicaid and private coverage, helps to ensure continuity of care for individuals with fluctuating incomes. The rule allows for states to receive funding for BHP beginning in 2015.

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CMS Bulletin on Retroactive Advance Payments of Premium Tax Credits and Cost Sharing Reductions in 2014 Due to Exceptional Circumstances

Posted on March 7, 2014

On February 27, 2014, CMS issued a Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the PTC and CSRs in 2014 Due to Exceptional Circumstances. Using its authority to establish special enrollment periods under the ACA, CMS created a mechanism for recognizing certain “exceptional circumstances” that arise when as a result of “technical issues in establishing automated eligibility and enrollment functionality,” Exchanges have experienced difficulties in making timely eligibility determinations and enrolling people during the initial open enrollment period.

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CMS rule extends transition policy to 2017

Posted on March 6, 2014

Yesterday, the Centers for Medicare and Medicaid Services issued the final rule on the Notice of Benefit and Payment Parameters for 2015. Several of the notable components of the rule include:

  • Extending the transitional policy from November 2013, which says that individuals may retain their insurance coverage even if it does not meet the Affordable Care Act (ACA) standards, through October 2016.
  • Finalizing that open enrollment for 2015 will being on November 15th, 2014 and conclude on January 15th, 2015.
  • Stabilizing the transitional reinsurance program by raising the attachment point and setting a reinsurance cap.
  • Refining the risk adjustment and risk corridor programs.
  • Implementing enrollee protections such as out-of-pocket limits and patient safety standards.
  • Finalizing provisions of the Small Business Health Options Program (SHOP) that address employee choice and premium aggregation.

In addition to the rule, Gary Cohen, the Director for the Center for Consumer Information and Insurance Oversight (CCIIO) released a letter explaining the extension of plans that do not meet the ACA meaningful coverage requirements. The letter further describes how states that did not implement this extension back in November may do so now.

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CMS guidance permits retroactive subsidy access

Posted on February 28, 2014

Guidance issued by the Center for Medicare and Medicaid Services (CMS) states that individuals who enrolled in health plans outside of the Affordable Care Act (ACA) insurance Marketplaces may retroactively receive premium subsidies. Under the ACA, advanced premium tax credits, or subsidies, are only available to individuals that purchased qualified health plans through the Marketplace. Many states have asked CMS to permit subsidies outside of the ACA Marketplace because IT issues prevented many eligible individuals from enrolling into QHPs before the deadline. Subsidies will retroactively be paid to insurers back to the effective date of plan enrollment.

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CMS issues DSH allotments

Posted on February 27, 2014

The Centers for Medicare and Medicaid Services (CMS) issued the funding allocation for disproportionate share hospitals (DSH) for FY 2014. DSH payments are typically provided to hospitals that treat a disproportionate number of uninsured or under-insured patients. The Affordable Care Act (ACA) originally called for a cut in DSH payments, as more Americans would presumably be insured under Medicaid. The Supreme Court ruling that made Medicaid expansion optional, however, ultimately coerced CMS to delay DSH cuts for two years.

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