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Rulemaking, Rules, and Guidance

CMS issues FAQ on Medicaid plan marketing rules

Posted on January 20, 2015

The Centers for Medicare and Medicaid Services (CMS) posted a document which clarifies whether Medicaid managed care plans can market their private qualified health plans (QHP) to potential enrollees. CMS says federal rules do not prohibit Medicaid plans from providing information about QHPs to potential enrollees who might enroll in such a plan as an alternative to the Medicaid plan. However, CMS recommends that plans consult contracts and their state Medicaid agencies for more information on what is allowed.

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HHS issues proposed rule on summary of benefits and coverage

Posted on January 5, 2015

The U.S. Department of Health and Human Services (HHS) issued a proposed rule, simultaneously released by the Internal Revenue Service (IRS) and the Department of Labor (DOL), regarding the summary of benefits and coverage (SBC) and the uniform glossary for health insurance coverage in the group and individual markets under the Affordable Care Act (ACA). The proposed rule would change disclosure requirements to help plans and individuals better understand their health coverage and allow for informed comparisons of coverage options. The proposed regulation also makes amendments to the template for the SBC, instructions, sample language, guides for coverage example calculations, and the uniform glossary.

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IRS issues proposed rule on excepted benefits

Posted on January 5, 2015

The Internal Revenue Service (IRS) issued a proposed rule, simultaneously released by the Department of Labor (DOL) and the U.S. Department of Health and Human Services (HHS), amending the conditions under which wraparound coverage can be considered an excepted benefit. The proposed regulation sets forth five requirements under which limited benefits provided through a group health plan that wrap around either eligible individual insurance or coverage under a Multi-State Plan constitute excepted benefits. These conditions include coverage of additional benefits, quantity limits, nondiscrimination, and plan eligibility and reporting requirements. The proposed rule also includes a pilot program that would allow limited wraparound coverage to be offered as excepted benefits to coverage for a limited time.

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CMS issues 2016 draft guidance on federal exchange participation

Posted on December 21, 2014

The Centers for Medicare and Medicaid Services published a draft letter to insurers who want to offer qualified health plans (QHP) in the federally run exchanges in 2016. The letter outlines key requirements that insurers must follow, including provider network and patient safety standards. It also explains how CMS plans to review plan rate increases and conduct oversight of marketing, agents, and brokers. The initial submission window for 2016 QHP applications would be from March 16 to April 15 2015. Certification notices and agreements with insurers would be sent between Aug. 17 and Sept. 15, according to the draft guidance.

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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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