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

Rulemaking, Rules, and Guidance

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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Insurance Affordability: Payment of premium and cost sharing payments made on behalf of enrollees by federal and state programs

Posted on April 2, 2014

Individuals purchasing qualified health plans and stand-alone dental plans (for the child component) through the Health Insurance Marketplace can qualify for premium subsidies and cost sharing reduction assistance if their modified adjusted gross incomes fall between 100% and 400% of the federal poverty level. Although as a matter of law the subsidies provided are deemed sufficient to make coverage affordable, for many individuals, the level of subsidy furnished is insufficient as a practical matter. Governmental programs such as the Ryan White Care Act and other federal and state programs may be available to help these individuals meet the cost of coverage by paying their share of premiums or assisting them with their portion of deductibles and other cost sharing. In recent weeks, however, news reports surfaced regarding the refusal by some insurers to accept payment made on behalf of enrollees.

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IRS guidance aids victims of domestic violence

Posted on March 26, 2014

Guidance issued by the Internal Revenue Service (IRS) permits married individuals separated from their spouses due to domestic violence to receive income-based premium tax credits. Typically, spouses are expected to file taxes jointly in order to be eligible for premium subsidies under the Affordable Care Act (ACA). Today’s guidance allows for an exception to this rule and also extends the enrollment deadline for this population by two months, through May 31st.

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Administration extends ACA enrollment

Posted on March 26, 2014

Today, the US Department of Health and Human Services (HHS) released guidance permitting extended enrollment for those seeking coverage under the Affordable Care Act’s (ACA) Health Insurance Marketplaces. The enrollment period, which was scheduled to end on March 31st, was extended in response to various circumstances that may have prevented eager enrollees to gain coverage within the specified time frame. One guidance document released by HHS specifies specific case scenarios in which an individual may be deemed eligible for extended enrollment, such as a natural disaster or Marketplace errors. A second document provides information for how individuals deemed “in-line” at the end of the enrollment period may still procure coverage after the deadline.

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Update: Expanded Federal Regulation of Navigators and Other Consumer Assistance Personnel

Posted on March 26, 2014

Federal regulations establish standards governing Navigator and non-Navigator consumer assistance programs. Navigators and non-Navigator assistance personnel must meet federal standards as well as state licensing and certification standards. Our prior update reviewed proposed federal rules that would clarify the criteria the federal government will apply in determining whether a state licensure or certification standard is preempted by federal law. The proposed rules also set additional federal standards governing Navigators and other consumer assistance personnel. Comments are due 30 days from publication of the proposed rule, which was published in the federal register on March 21, 2014.

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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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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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IRS issues new ACA-related rules

Posted on March 6, 2014

A final rule released by the Internal Revenue Service (IRS) addresses the reporting requirements for large employers under the Affordable Care Act (ACA). Beginning in 2015, employers with more than 50 full-time employees are required to offer quality and affordable insurance to their employees. The new rule provides a methodology designed to simplify and reduce the costs associated with the employer reporting requirements mandated under the ACA. Another final rule issued by the IRS describes how issuers of minimum essential coverage are expected to report information to the IRS on the type and duration of coverage.

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