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

Tag: Final Rule

Rule finalizes 90-day waiting limit

Posted by Nikki Hurt on June 20, 2014

Today, the US Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA) released a final rule concerning the 90-day waiting period limitation. The final rule states that group health insurance plans cannot apply a waiting period that exceeds 90 days after the employee has been approved for coverage. The rule further states that small group plan orientation periods, the time it takes from hire to when the plan deems the employee is eligible for coverage, cannot exceed one month.

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HHS releases final Marketplace rule

Posted by Nikki Hurt on May 16, 2014

The US Department of Health and Human Services (HHS) issued a final rule entitled Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond. Some specific provisions in the rule include:

  • Raising the administrative costs and profits ceiling under the risk corridor formula by 2%.
  • Providing information on how to include ICD-10 costs under the medical loss ratio (MLR).
  • Requiring qualified health plans (QHP) on the ACA Marketplace to have a more efficient and effective method for enrollees to acquire medications not covered on the plan. This specifically applies to enrollees on a course of treatment in which absence of the medication would substantially impact the individual’s life and health.
  • Requiring insurers to annually report plan changes to beneficiaries.
  • Beginning in 2016, Marketplaces will have to display quality data on all plans for public viewing. The data will be based on a five-star system and enrollee satisfaction surveys.
  • Enumerating state requirements that may prohibit Navigators or other assistors from performing their roles. For example, Navigators may go door-to-door for enrollment assistance and outreach. They may not, however, provide gifts to entice enrollment.
  • Delaying the “employee choice” option in the small business health options program (SHOP) to 2016.

The final rule is largely unchanged from the proposed version. An FAQ addressing market reforms and Marketplace standards can also be accessed here.

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New CMS rule reduces burden and promotes efficiency

Posted by Nikki Hurt on May 8, 2014

A final rule released by the Centers for Medicare and Medicaid Services (CMS) is designed to loosen policies that could save hospitals up to $3.2 billion over the next five years. One policy addressed removes the requirement that a physician must be present at a rural health center every two weeks, which was implemented to help combat the shortage of rural health providers. The rule also relaxes supervision requirements for some providers, such as dieticians. Easing regulations under this rule follows suit with the administration’s “regulatory lookback” that began in 2012.

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Update: Basic Health Program Final Regulations

Posted by Nikki Hurt on March 12, 2014

On March 7, 2014, the Centers for Medicare and Medicaid Services (CMS) published final regulations implementing the Affordable Care Act’s Basic Health Program (BHP) market option (PPACA §1331). On that date, CMS also published rules that set forth the BHP payment methodology and the data it will use to determine payments to states that establish certified BHP programs.

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CMS releases BHP final rule

Posted by Nikki Hurt 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 rule extends transition policy to 2016

Posted by Nikki Hurt on March 6, 2014

Yesterday, the Centers for Medicare and Medicaid Services issued the final rule on the Notice of Benefit and Payment Parameters for 2015. Several of the notable components of the rule include:

  • Extending the transitional policy from November 2013, which says that individuals may retain their insurance coverage even if it does not meet the Affordable Care Act (ACA) standards, through October 2016.
  • Finalizing that open enrollment for 2015 will being on November 15th, 2014 and conclude on January 15th, 2015.
  • Stabilizing the transitional reinsurance program by raising the attachment point and setting a reinsurance cap.
  • Refining the risk adjustment and risk corridor programs.
  • Implementing enrollee protections such as out-of-pocket limits and patient safety standards.
  • Finalizing provisions of the Small Business Health Options Program (SHOP) that address employee choice and premium aggregation.

In addition to the rule, Gary Cohen, the Director for the Center for Consumer Information and Insurance Oversight (CCIIO) released a letter explaining the extension of plans that do not meet the ACA meaningful coverage requirements. The letter further describes how states that did not implement this extension back in November may do so now.

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Tri-agency rules address 90-day waiting period limit

Posted by Nikki Hurt on February 20, 2014

The US Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA) released several rules today concerning the 90-day waiting period limitation before insurance coverage can become effective. The final rule states that group health insurance plans cannot apply a waiting period that exceeds 90 days beginning January 2015. The proposed rule clarifies the 90-day limitation in terms of the length of employment-based orientation periods, stating that one month is the reasonable limit for employment-based orientation periods.

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IRS issues two ACA rules

Posted by Nikki Hurt on November 29, 2013

The Internal Revenue Service (IRS) published two final rules concerning the implementation of the Affordable Care Act (ACA). The first rule outlines the health insurance provider fees firms in the insurance industry are expected to provide annually, beginning in 2014. These fees are anticipated to raise nearly $60 billion in revenue over the next several years, most of which will be used as subsidies for qualifying individuals to purchase insurance through health insurance marketplaces. The fee applies to insurance companies with annual revenues exceeding $25 million. Nonprofit insurers receiving more than 80% of their funds from the government, self-insured corporations, and government entities are all excluded from the fee.

The second rule addresses the Additional Medicare Tax provision of the ACA, which requires an additional hospital insurance tax on individuals with incomes above the specified threshold. The rule concerns the implementation and integration of the Additional Medicare Tax, specifically highlighting certain wages and compensation to which the tax does not apply, filing a tax return, and employer processes for adjusting payments and filing claims under the Additional Medicare Tax.

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Administration issues mental health final rule

Posted by Nikki Hurt on November 8, 2013

The Department of Health and Human Services (HHS), Department of Labor (DoL), and the Department of the Treasury (DoT) released the joint final rule implementing the Mental Health Parity and Addiction Equity Act of 2008. Under this law, insurers that offer coverage for mental health services are expected to treat mental health equitably, meaning cost-sharing and limits for mental health services should be comparable to that of physical health services. Several other specific provisions addressed in this rule include:

  • Parity for intermediate care offered in residential or outpatient settings and all plan standards (i.e. network adequacy and geographic limits);
  • Clarifying transparency expectations for insurers to remain compliant with the law; and
  • Eliminating provisions that enabled insurers to make exceptions for parity requirements for certain benefits offered.

The law was passed in 2008, and an interim final rule was issued in January 2010. The Centers for Medicare and Medicaid Services (CMS) also published an FAQ on today’s rule.

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Update: Medicaid DSH Final Rule

Posted by Nikki Hurt on October 8, 2013

On September 13th, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a final rule concerning the reduction of Medicaid Disproportionate Share Hospital (DSH) payments to hospitals. The reduction methodology discussed in this rule will be effective for FY 2014 and FY 2015…

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