Rulemaking, Rules, and Guidance

CCIIO provides additional guidance on Navigators and Marketplace assistance

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.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Insurance, Key Developments, Office of Consumer Information and Insurance Oversight, Rulemaking, Rules, and Guidance

CCIIO releases Marketplace FAQ

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.”

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IRS updates guidance with MLR proposed rule

Posted on May 14, 2013

According to a proposed rule released by the Internal Revenue Service (IRS), “activities that improve health quality” can not be used to determine Blue Cross and Blue Shield’s Medical Loss Ratio (MLR) in regards to obtaining their tax-exempt status. According to the Affordable Care Act (ACA), insurance companies lose their tax privilege under tax code Section 833 and the MLR if they do not spend 85% of their premium revenue on enrollee medical services. Until this proposed rule was released, interim guidance permitted insurance companies to count health care quality activities toward their 85%.

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Categories: Department of the Treasury, Health Insurance, Internal Revenue Service, Key Developments, Rulemaking, Rules, and Guidance

CMS releases DSH payment proposed rule

Posted on May 14, 2013

The Centers for Medicare and Medicaid Services (CMS) released a proposed rule concerning reductions to Disproportionate Share Hospital (DSH) payments. Pursuant to the Affordable Care Act (ACA), the federal government had intended to cut DSH payments beginning in 2014, as the law’s Medicaid expansion would negate the need for such payments. Since the Supreme Court’s decision rendered Medicaid expansion optional, the federal government has elected to delay the DSH payment reduction until 2015 when they have a more accurate assessment of the nation’s uncompensated care level after initial implementation of the ACA.

A fact sheet summarizing the rule can be found here.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Key Developments, Medicaid and CHIP, Rulemaking, Rules, and Guidance

EBSA preliminary guidance requires employers to notify employees about insurance options

Posted on May 10, 2013

The Employee Benefits Security Administration (EBSA), a division of the Department of Labor, published guidance concerning employer notification of insurance options in the health insurance marketplaces established by the Affordable Care Act (ACA), including model language for employers to notify their employees on marketplaces and employer-sponsored coverage. Technical Release Number 2013-02 states that employers must begin to inform their employees about available insurance options beginning October 1st, and the guidance contains a model notice for employers to utilize. EBSA released this guidance in advance of the proposed rule so that employers are equipped with the appropriate knowledge so they may begin to notify employees as soon as they desire.

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Categories: Department of Labor, Employee Benefit Security Administration, Health Insurance, Key Developments, Rulemaking, Rules, and Guidance

CCIIO provides Model Language for issuers

Posted on May 8, 2013

The Center for Consumer Information and Insurance Oversight (CCIIO) provided permissible Model Language for issuers to use when notifying existing customers of the new plan options that will be available to them through the Affordable Care Act’s (ACA) health insurance marketplaces. CCIIO provided several examples as to how issuers may phrase their notices, and gives issuers the flexibility to either provide the notice by itself or as part of the customer’s policy renewal notice. Furthermore, issuers of qualified health plans (QHP) and non-grandfathered health plans are barred from using practices that would discourage enrollment of those with poor health statuses.

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CCIIO issues agent and broker guidance

Posted on May 2, 2013

The Center for Consumer Information and Insurance Oversight (CCIIO) released new guidance detailing the roles of agents, brokers and web-brokers in the health insurance Exchanges. The letter claims that State-Based Exchanges may establish their own regulations on the amount insurers can pay brokers, while Federally-Facilitated Exchanges, which also includes State-Partnership Exchanges, will not create commission schedules or pay commission directly to the brokers. CCIIO also purported that they will re-evaluate the requirement that brokers receive the same compensation for selling plans outside of the Exchanges as they would for selling qualified health plans (QHP). Brokers are anticipated to play a role in educating consumers entering into the Exchange, and the Centers for Medicare and Medicaid Services (CMS) will be responsible for registering and training agents and brokers to help consumers in the QHP selection process. States, however, will retain the authority to license and regulate brokers and agents.

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IRS releases NPRM on employer coverage and tax credits

Posted on April 30, 2013

The Internal Revenue Service (IRS) issued a proposed rule discussing the minimum value of employer-sponsored health coverage and the ability of employees to receive premium assistance tax credits. According to the proposed rule, IRS states that the minimum value would be determined by dividing the cost of certain benefits to the standard population by the cost of all benefits, including employee cost-sharing and plan payments, and converting that value to a percentage. Several values, such as the amount contributed by employer’s to health savings accounts, will be considered in determining the employer’s share of costs. However, IRS has also proposed that employer contributions to wellness incentive programs does not count toward health plan minimum value. Additionally, the proposed rule also states that employee-sponsored large group plans are not beholden to every essential health benefit category (EHB), nor must they design their plans to mimic the EHB standards that apply to qualified health plans offered in the Exchange. Adherence to the minimum value requirements will prevent employers from paying the employee shared responsibility payment penalties and will render their employees ineligible for premium assistance tax credits in the Exchange.

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Categories: Department of the Treasury, Health Insurance, Internal Revenue Service, Key Developments, Rulemaking, Rules, and Guidance

CCIIO releases FAQ on market reforms

Posted on April 29, 2013

The Center for Consumer Information and Insurance Oversight (CCIIO) released a set of eight questions on implementation of the Affordable Care Act (ACA). Specifically, this guidance clarifies the limitation provided in the Market Rule final rule stating that a plan issuer may have one geographic rating factor for each approved geographic rating area per single risk pool in a given state. The following topics are addressed in the FAQ to expand upon the meaning of this limitation:

Withdrawal of non-grandfathered business
Maintenance of alternative mechanisms
Geographic rating areas
Definition of association coverage
Premium adjustment when coverage becomes secondary to Medicare

Issuers submitting plans to the federally-facilitated Exchanges may make necessary changes to their plans in order to comply with this new guidance.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Health Information, Key Developments, Office of Consumer Information and Insurance Oversight, Rulemaking, Rules, and Guidance

CMS releases annual hospital IPPS rule

Posted on April 29, 2013

The Centers for Medicare and Medicaid Services (CMS) released a proposed rule of more than 1400 pages describing the new Medicare payment schedule for 2014. The annual Acute Care Hospital Inpatient Prospective Payment System (IPPS) rule proposes that general acute-care hospitals will see a payment increase of 0.8% and long-term care hospitals will see their payments rise by 1.1%. Pursuant to the Affordable Care Act (ACA), the NRPM also details the new penalty program for hospitals that do not reduce nosocomial infections, adding hip and knee implants and chronic obstructive pulmonary disorder to the 30 day readmission penalty program. Another component of the proposed rule alters Medicare disproportionate share hospital (DSH) payments. Additional payments to each hospital will be made based upon its percentage of the total uncompensated care rendered at all DSH hospitals at a given time, ultimately reducing overall DSH payments by 0.9%. Furthermore, hospitals that do not participate in the Hospital Inpatient Quality Reporting (IQR) Program will be subject to additional penalties.

Comments will be due by June 25th, 2013.

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Categories: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Key Developments, Medicare, Rulemaking, Rules, and Guidance