Rulemaking, Rules, and Guidance

CMS issues final rule on Medicaid DSH

Posted on December 3, 2014

The Centers for Medicare and Medicaid Services issued a final rule addressing the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments. Under this limitation, DSH payments to a hospital cannot exceed the uncompensated costs of furnishing services to individuals who are Medicaid-eligible or uninsured. The final rule defines “uninsured” as those who have “no health insurance for the services furnished during the year.” The rule also provides that determinations of funding limits will be made on a service-specific basis rather than at the individual level. CMS says the regulation gives states and hospitals more flexibility in terms of which hospital costs can be considered uninsured costs than what had been in place under a final rule from 2008.

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CMS issues guidance on re-enrollment in the FFM

Posted on December 2, 2014

The Centers for Medicare and Medicaid Services (CMS) announced in guidance that it will create an “Enrollee Switched List” that allows issuers participating in federally facilitated exchanges to identify enrollees who actively re-enrolled in coverage with another issuer. However, enrollees who completed an active selection to change plans with the same issuer will not be included on the list because the issuer will be aware of the plan change via the active enrollment transaction. The guidance comes in response to issuer concerns that CMS’s decision to not send termination notices to issuers when members select other plans could result in duplicate billings and other problems.

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CMS issues proposed rule on Medicare ACOs

Posted on December 2, 2014

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule, which addresses changes to the Affordable Care Act’s (ACA) Medicare Shared Savings Program, including provisions relating to the payment of Accountable Care Organizations (ACO) participating in the Program.  The proposed rule includes several changes to eligibility requirements, definitions of an ACO participant, and how “pioneer” ACOs transition into the Medicare Shared Savings Program.  Notably, the rule would allow ACOs an extra three years without risk of penalties for poor performance, albeit with smaller shared savings for good performance. CMS also is considering making it easier for ACOs to meet spending targets by comparing them to providers in their region, instead of national comparisons, and by gradually making benchmarks less dependent on past ACO performance.

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HHS releases proposed rule on open enrollment

Posted on November 22, 2014

The U.S. Department of Health and Human Services (HHS) issued a proposed rule that would set future annual exchange open enrollment periods so that they begin October 1 and end December 15. Consumers selecting a plan during this time period would gain coverage starting January 1, 2016. HHS says this time period will be long enough for consumers to pick or change their plan, but not crossing calendar years will reduce consumer confusion. The proposed rule also touches on key aspects of the Affordable Care Act (ACA), including risk corridors, user fees for the federal exchange, essential health benefits, and network adequacy.

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OPM issues proposed rule for Multi-State Plan Program

Posted on November 22, 2014

The U.S. Office of Personnel Management (OPM) issued a proposed rule to implement modifications to the Multi-State Plan (MSP) Program. The MSP Program is a provision of the Affordable Care Act (ACA) designed to offer at least two federally administered plans in all 50 states. The proposed rule would revise sections of a final 2013 rule, adjusting the requirements on multi-state plans and the insurers that offer them, based on OPM’s experience since the final rule was issued.

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IRS issues guidance on coverage of hospital services

Posted on November 5, 2014

New guidance issued by the Internal Revenue Service (IRS) states that employers must provide substantial coverage for in-patient hospitalization services in order to meet minimum Affordable Care Act (ACA) standards. Plans that fail to provide this coverage do not provide the minimum value intended by the minimum value requirement of the ACA. According to the guidance, any employer that has contracted with such a plan before this guidance was issued will be excluded from the requirement in 2015 if its plan year begins on or before March 1.

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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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DOL issues final rule on excepted benefits

Posted on September 30, 2014

The Department of Labor (DOL) issued a final rule regarding excepted benefits and stand-alone dental and vision plans. In the original proposed rule if the wraparound coverage met a number of requirements, it would have been considered an excepted benefit that would not disqualify the employee from getting subsidized coverage on the exchanges. However, this language is excluded from the final rule issued. The DOL said it intends to publish regulations on the topic of wraparound coverage in the future, taking into account the extensive comments received on the topic.

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IRS issues final rule on ACA write-off limit

Posted on September 19, 2014

The Internal Revenue Service (IRS) finalized a half-million-dollar cap on deductions that the biggest insurance companies can take for executive pay. This final rule will affect certain health insurance providers giving remuneration that exceeds the deduction limitation. According to a recent analysis, the little-known Affordable Care Act (ACA) provision amounted to about $1.3 million per executive for the largest insurers in 2013. The rule details what companies and employees are subject to the limit and how it should be applied.

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