Tag: CMS

HHS proposed rule covers a slew of ACA provisions

Posted by Nikki Hurt on June 14, 2013

Today, the US Department of Health and Human Services released a proposed rule addressing various facets of the Affordable Care Act (ACA). The 253 page document expands upon guidance previously released to states and stakeholders, covering topics ranging from financial integrity and additional oversight of Exchanges to options available under the Small Business Health Options Program (SHOP). Key provisions provided in the proposed rule include:

• Qualified health plans must accept a wide variety of payment options for premiums. A recent Jackson Hewitt study found a large number of uninsured Americans lack bank accounts, and restrictive payment policies excluding money orders and prepaid debit cards would impede the ability of these uninsured Americans to gain insurance access.
• Additional guidance was provided for federally-facilitated Exchange (FFE) states that choose to operate their own SHOP market while the federal government maintains oversight of their individual market, known as the Utah plan. The proposed rule states that data sharing requirements between SHOP and individual markets do not apply in these arrangements. Additionally, states operating their own SHOP Exchange can have their own set of Navigators, separate from the individual market, that perform outreach to small businesses.

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CMS releases additional hospital spending data

Posted by Nikki Hurt on June 3, 2013

In an expansion to the hospital charges data released last month, the Centers for Medicare and Medicaid Services (CMS) provided data describing charges for 30 different outpatient procedures. The data include charge estimates for Ambulatory Payment Classification Groups, which are paid under the Medicare Outpatient Prospective Payment System. Presented data are hospital-specific and report charge values collected during calendar year 2011.

CMS also released data on geographic variations in Medicare public use and Medicare utilization by those with chronic conditions.

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HHS final rule officially delays employee choice in SHOP implementation

Posted by Nikki Hurt on May 31, 2013

In a final rule released today, the US Department of Health and Human Services (HHS) finalized the decision to delay the employee choice provision in federally-facilitated Small Business Health Option Program (SHOP) markets until 2015. The employee choice model within the Affordable Care Act (ACA) permits employers to select a medal tier level (bronze, silver, gold or platinum). Their employees will then be able to enroll into any qualified health plan (QHP) available at that tier. As a result of this final rule, employees will only be able to enroll into the single QHP selected by their employer. HHS cited the implementation delay as necessary to ensure the stability of the program, purporting the extra time will enable the agency to better prepare for the employee choice model. In addition to this provision, the final rule establishes a 30-day SHOP enrollment period. The SHOP enrollment period will now be concurrent to the enrollment period for the group market as established by the Health Insurance Portability and Accountability Act (HIPAA).

The Centers for Medicare and Medicaid Services (CMS) also published the final SHOP applications for employers and employees.

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Administration released final rule on employee-sponsored wellness programs

Posted by Nikki Hurt on May 29, 2013

A joint rule released by the US Department of Labor (DoL), the US Department of the Treasury (DoT), and the US Department of Health and Human Services (HHS) addresses new provisions regarding participatory wellness programs in the workplace. Workplace wellness programs are designed to reduce the prevalence of chronic disease, stifle growing health care costs, and improve overall health by rewarding employees for participating in certain activities, such as educational classes or obtaining memberships to fitness centers. The final rule sets the maximum reword for completion of a nondiscriminatory health-contingent wellness program to 30% of coverage costs, up from the original 20%. Employees that successfully complete tobacco-related wellness programs are eligible for up to 50% of cost of coverage.

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Health Information Implications of the 2014 HHS Budget

Posted by Nikki Hurt on

On April 10, 2013, President Obama released his proposed FY 2014 budget, which includes $967.3 billion in outlays for the Department of Health and Human Services (HHS) and makes legislative proposals that would save an estimated $361.1 billion (net) over ten years. In conjunction with the release of the President’s budget, HHS published an overview of the budget provisions for HHS, which provides more detail on how the Department would allocate its budget in FY 2014 and describes its ongoing progress in meeting specific program goals and legislative requirements. Many of the proposals included in the President’s budget and HHS’ overview relate to the ongoing transformation of the health care delivery system to a value-based system that rewards quality and efficiency. Critical to the success of this transformation is the exchange of health information for activities such as quality measurement and reporting, value-based purchasing, consumer engagement, and comparative effectiveness research. Below are selected provisions of the HHS budget, the agency’s relevant legislative proposals for 2014, and progress reports for health care system reform efforts that require the use and exchange of health information. We also identify HHS’ stated priorities for 2014 that are related to health information…

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CMS State Resources FAQ: Medicaid Eligibility Determinations, Medicaid/Exchange Interactions, and §1115 Demonstrations that Use Enrollment Caps

Posted by Nikki Hurt on May 22, 2013

The interaction between Medicaid and Exchanges around eligibility determination issues represents one of the most important and complex aspects of the ACA. An estimated 28 million adults, along with 19 million children, can be expected to transition at least once annually between insurance affordability programs, as Medicaid and premium subsidies are termed under implementing CMS regulations. Collaboration between Medicaid agencies and Exchanges is essential in order to avert unnecessary delays in eligibility determinations and breaks in coverage that in turn can affect not only the affordability of care but access itself, given the link between coverage and health care access through plans’ provider networks…

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CMS letter addresses enrollment strategies for Medicaid and CHIP

Posted by Nikki Hurt on May 20, 2013

The Centers for Medicare and Medicaid Services (CMS) released a letter to state health officials and Medicaid Directors regarding enrollment of uninsured individuals into Medicaid and CHIP. With the looming enactment of the Affordable Care Act’s (ACA) provision on Medicaid expansion, CMS intends to assist states by providing optional tools that will aid in their transition to the new eligibility and enrollment models. The letter specifically addresses and provides guidance on these five enrollment strategies:

• Implementing the early adoption of Modified Adjusted Gross Income (MAGI)-based rules;
• Extending the Medicaid renewal period so renewals that would otherwise occur during the first quarter of calendar year 2014 will occur later;
• Enrolling individuals into Medicaid based upon Supplemental Nutrition Assistance Program (SNAP) eligibility;
• Enrolling parents into Medicaid based upon children’s income eligibility; and
• Adopting 12-month continued eligibility for parents and other adults.

CMS purports that states choosing to utilize one of these outlined approaches will be met with a streamlined review and approval process.

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CMS rule requires MA and Medicare Part D to comply with MLR

Posted by Nikki Hurt on

The Centers for Medicare and Medicaid Services (CMS) released a final rule that requires Medicare Advantage (MA) and Medicare Part D issuers to comply with the medical loss ratio (MLR), which states that these issuers must spend 85% of their premium revenues on patient services. The MLR permits only 15% of this revenue to be spent on organization administrative and overhead costs. MA and Part D issuers are required to submit data to CMS that allows consumers to use the sponsor’s MLR as a measure of efficiency. If the plan sponsors do not meet the MLR requirements, they will be subject to financial penalties, enrollment sanctions, and potential contract termination if issuers repeatedly miss the minimum MLR requirement.

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CMS sets PCIP payment at Medicare rates

Posted by Nikki Hurt on

In an Interim Final Rule released Friday, the Centers for Medicare and Medicaid Services (CMS) stated that as of June 15th, payment rates for the federal Pre-Existing Condition Insurance Plan (PCIP) will be set to those of Medicare. Until the passage of the Affordable Care Act (ACA), many Americans with pre-existing conditions were denied insurance coverage or charged exorbitantly high premiums. PCIP, which was created under the ACA, was allocated $5 billion to enable those with pre-existing conditions to obtain insurance prior to 2014. 135,000 otherwise uninsured individuals with pre-existing conditions were granted coverage under PCIP, with claims averaging $32,108 per enrollee. Changes in PCIP payments were authorized in order to ensure program solvency until 2014. One specific example is the provision in which payments to skilled nursing facilities may be reduced by 50% as of June 15, 2013.

Enrollment in federal PCIP programs was capped in February due to funding concerns. Enrollment in the 27 state-operated PCIP programs was suspended several weeks later. As of now, 17 of the state-operated PCIP programs will be administered by the US Department of Health and Human Services (HHS) for the duration of the year.

Enrollment in federal PCIP programs was capped in February due to funding concerns. Enrollment in the 27 state-operated PCIP programs was suspended several weeks later. As of now, 17 of the state-operated PCIP programs will be administered by the US Department of Health and Human Services (HHS) for the duration of the year.

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CCIIO provides additional guidance on Navigators and Marketplace assistance

Posted by Nikki Hurt 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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