CMS Bulletin on Retroactive Advance Payments of Premium Tax Credits and Cost Sharing Reductions in 2014 Due to Exceptional Circumstances
Posted on March 7, 2014
On February 27, 2014, CMS issued a Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the PTC and CSRs in 2014 Due to Exceptional Circumstances. Using its authority to establish special enrollment periods under the ACA, CMS created a mechanism for recognizing certain “exceptional circumstances” that arise when as a result of “technical issues in establishing automated eligibility and enrollment functionality,” Exchanges have experienced difficulties in making timely eligibility determinations and enrolling people during the initial open enrollment period.
CMS 2015 Draft Letter to Issuers in the Federally Facilitated Marketplace: Network Adequacy and Inclusion of Essential Community Providers
Posted on March 5, 2014
In administering the FFM, CMS utilizes Issuer Letters to apprise issuers potentially interested in offering qualified health plans (QHPs) in the Marketplace regarding priorities and policies for the agency. In effect, CMS acts like a plan sponsor in managing the FFM, although unlike other sponsors (e.g., employers), the FFM has not, to date, been selective about which plans may be sold in the Marketplace. That is, plans that meet FFM (and where applicable, state) certification standards are eligible to be sold. At the same time, QHPs must meet a range of certification standards, and in its oversight capacity, CMS uses its Issuer Letters as a means of clarifying policy and delineating areas of emphasis for health plans.
When Does Medicaid Coverage Amount to Minimum Essential Coverage Under the Affordable Care Act? An Update on the Treasury/IRS Rules Defining Minimum Essential Coverage
Posted on February 11, 2014
A January 27, 2014 proposed rule in the Federal Register (79 Fed. Reg. 4302-4308) published by Treasury/IRS would add further clarification to the question of under what circumstances the agencies will classify Medicaid as minimum essential coverage (MEC) for purposes of satisfying the Affordable Care Act’s requirement to maintain MEC or pay a shared responsibility tax. Comments are due by April 28, 2014; the agencies also intend to hold a public hearing on the NPRM which covers Medicaid as well as other types of coverage.
Posted on January 6, 2014
As discussed in earlier Briefs, the ACA requires all individual and non-grandfathered group health plans to cover certain preventive services, including comprehensive contraceptive services. On August 3, 2011, the Departments of Treasury, Labor, and Health and Human Services (HHS) published an Amended Interim Final Rule incorporating HRSA’s guidelines to require mandatory coverage by non-grandfathered group and individual insurance plans of all preventive services (including contraception) without cost sharing beginning on August 1, 2012. Religious employers and other interested parties argued that requiring employers to sponsor insurance that included contraception violated religious liberty...
Questions and Answers about the Administration’s Transition Plan to Address Health Insurance Policy Cancellations
Categories: Health Insurance
Posted on November 18, 2013
On November 14th, 2013, the Obama Administration announced a plan to address a situation that began to emerge in earnest a number of weeks ago and that finally exploded into view within the past couple of weeks: people covered by individual insurance plans who were receiving notices from their insurers that their policies would be cancelled at the end of 2013 because they did not meet new coverage requirements set to take effect in January 2014. The number of people affected by policy cancellation notices is not clear, but most estimates suggest that one half or more of the 15 million people in the individual market could be affected. Manhattan Institute scholar Avik Roy placed the number at 4.8 million (so far). Washington Post reporter Sarah Kliff noted that the figure is hard to calculate but is likely to affect between 7 and 12 million people.
Posted on October 16, 2013
This Implementation Brief examines a Notice of Proposed Rulemaking (NPRM) issued by the Internal Revenue Service (IRS) on August 26, 2013 concerning the tax credit available to small employers that offer health insurance coverage to their employees...
Categories: Health Insurance
Posted on October 10, 2013
By Taylor Burke Introduction On August 30, 2013, HHS published a final rule entitled “Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, and Eligibility Appeals.” This rule finalizes certain policies proposed in the Program Integrity NPRM published June 19, 2013, as well as certain policies proposed in the NPRM entitled “Essential Health Benefits [...]
Categories: Health Insurance
Posted on October 3, 2013
On September 25, 2013, the Obama Administration published a Notice of Proposed Rulemaking in the Federal Register (78 Fed. Reg. 59122) that implements §1331 of the Affordable Care Act, which directs the Secretary to establish a Basic Health Program (BHP). The long-delayed proposed rule reflects extensive consultation with stakeholders, a Request for Information (76 Fed. Reg. 56767) published on September 14, 2011, and a series of “listening sessions” to gather input. The comment period runs until 5 p.m., November 25, 2013. This update provides a background on the BHP and summarizes the proposed rule...
Update: Appealing Individual Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
Categories: Health Insurance
Posted on September 19, 2013
Section 1411(f) of the Affordable Care Act requires the HHS Secretary to establish a federal appeals process covering appeals related to certain determinations made by Health Insurance Marketplaces: eligibility for enrollment in a QHP sold in the Marketplace; eligibility for premium tax credits and cost-sharing reductions; exemptions from individual responsibility to maintain minimum essential coverage; citizenship and lawful presence; the affordability of employer coverage; and inconsistencies involving information.
Update on Eligibility for Exemptions from the Personal Responsibility Tax Penalty and Designating Certain Health Benefits Coverage as Minimum Essential Coverage
Categories: Health Insurance
Posted on July 31, 2013
On July 1, 2013, HHS issued final implementing regulations that specify which individuals may be eligible for exemptions from the Shared Responsibility penalty payment, a special tax established under the Affordable Care Act (ACA) that applies to non-exempt individuals who have access to affordable insurance but fail to purchase it. The final rule also explains the role of Exchanges in granting “certificates of exemption” from the penalty payments, and identifies the range of health benefits that the government will consider as satisfying the Act’s “minimum essential coverage” rule. The final rule shows some, but not a lot, of changes from its original proposed form.
Update: Reporting Information about Employer Coverage for Purposes of Shared Responsibility and Premium Assistance: Transitional Relief for 2014
Posted on July 23, 2013
On July 2, 2013, the Obama Administration posted a blog announcing a one-year delay (from 2014 to 2015) in implementing the shared responsibility provisions of the Affordable Care Act (ACA) applicable to large employers. The blog was followed by brief IRS policy guidance, as well as by a final HHS rule implementing the process by which Exchanges will ascertain the eligibility of individuals who apply for premium tax credits because they lack access to “affordable” employer-sponsored coverage that provides “minimum value.”
Update: Final Rule on Medicaid and CHIP, Including Essential Health Benefits in Alternative Benefit Plans; Eligibility Notices, Fair Hearings and Appeals Processes; Premiums and Cost Sharing; and Exchange Eligibility and Enrollment
Posted on July 16, 2013
On July 5, 2013, the Obama Administration published final rules implementing various provisions of the Affordable Care Act related to Medicaid and CHIP, premiums and cost-sharing, and Exchange eligibility and enrollment. This Update discusses the highlights of this very long rule, which modifies final regulations published in March 2012 as well as previous proposed regulations. The final rule contains four major parts: A. Medicaid Eligibility Part II Final Rule B. Essential Health Benefits in Alternative Benefit Plans C. Exchanges: Eligibility and Enrollment D. Medicaid Premiums and Cost-sharing In general, the final rule was adopted with very few changes. At the same time, CMS noted that certain aspects of the proposed rules remain un-finalized, pending additional implementation activities, including further changes necessitated by the Administration’s decision to delay employer compliance-related reporting requirements in connection with the Act’s employer responsibility provisions.
Categories: Health Insurance
Posted on June 26, 2013
Final regulations published in the June 3rd Federal Register (at 78 Fed. Reg. 33158) implement the ACA amendments to pre-existing federal laws permitting employer-sponsored health plans and health insurers selling products in the group insurance market to include in those products “non-discriminatory wellness programs”. The regulations were released jointly by the federal Departments of Labor, Treasury, and Health and Human Services. An earlier Implementation Brief examined the rules in their proposed form. The final rule largely retains the elements of the proposed rule, while also making important clarifications regarding how a wellness program must be structured in order to be considered non-discriminatory based on health status. Because the final regulations revise previous rules issued in 2006, the wellness program standards apply to both grandfathered and non-grandfathered plans, since the revisions simply restructure older standards rather than creating new ones.
Posted on June 21, 2013
On June 18, the non-partisan Congressional Budget Office (CBO) released two analyses of the effects of the current Senate bill on immigration reform – the Border Security, Economic Opportunity and Immigration Modernization Act, S. 744, as designed by the bipartisan “Gang of Eight” Senators and then amended and approved by the Senate Judiciary Committee. The bill is now being considered on the Senate floor. The bill is still being debated, so the findings could change as the legislation moves forward. The first analysis examines the overall macroeconomic impact of S. 744, while the second provides CBO’s estimate of the federal budget impact of the bill as passed by the Senate Judiciary Committee.
Will Uninsured People Who Lack Bank Accounts be Able to Participate in the Health Insurance Marketplace? CMS’ Proposed Rules
Categories: Health Insurance
Posted on June 20, 2013
A report issued in May 2013 by Jackson Hewitt Tax Service found that 27% of the uninsured, non-elderly population with household incomes in premium tax credit eligibility range are “unbanked” (that is, they lack either credit cards or bank accounts). Because many insurance companies require that premiums be paid with a credit card, by check, or by other electronic means, the unbanked uninsured effectively would be barred from coverage as well as from the premium tax credits whose purpose is to make coverage affordable. The problem is expected to fall most heavily on people already at risk for disparities in health and health care: African American and Latino families, families headed by unmarried adults and adults with low education levels, unemployed persons, and the poor...
Posted on May 16, 2013
The ACA contains numerous provisions affecting patient cost-sharing, both generally and in relation to specific services. Some of the provisions (such as those related to preventive services and annual limits on out-of-pocket cost-sharing) apply across multiple coverage markets (i.e., to health insurance products sold in both the individual and group markets as well as to self-insured plans). Other provisions, such as those governing deductibles applicable to the essential health benefit (EHB) package, apply only to those markets that are subject to the EHB requirement, i.e., health plans sold in the individual and small group (under 100 full-time employees) market. In general, the cost-sharing rules exempt grandfathered health plans.
Posted on May 8, 2013
On March 11, 2013, the U.S. Department of Health and Human Services (HHS) released a final rule on the Notice of Benefit and Payment Parameters for 2014. This final rule addresses a variety of issues, including the specific payment parameters for the three premium stabilization programs – the permanent risk adjustment program, the transitional reinsurance program, and the temporary risk corridors program. In addition, the final rule also covers advance payments of the premium tax credit, cost-sharing reductions, and user fees for the federally-facilitated Exchanges, specific requirements related to the federally facilitated Small Business Health Option Program (SHOP), and the medical loss ratio program. This rule finalizes the provisions set forth in HHS’s proposed rule on these topics, December 7, 2012...
Interim Final Rule: Alternative Approaches to Cost-Sharing Reduction Payment and Risk Corridor Calculations
Posted on May 8, 2013
The temporary risk corridors program allows the federal government to share a QHP’s profits or losses among other QHP issuers due to inaccurate rate setting inside the Exchanges from 2014-2016. To determine whether a QHP issuer has inaccurately set premium rates that lead to an unjustified profit or loss, a QHP’s “allowable costs” must be calculated per the requirements in the Premium Stabilization Rule. The IFR modifies the definition of “allowable costs” such that a QHP’s allowable costs are to be determined based on its pro-rata share of the QHP issuer’s incurred claims for all non-grandfathered health plans within a state, and allocated to the QHP based on premiums earned by the issuer in the market...
Categories: Health Insurance
Posted on May 1, 2013
This Age Curve portion of the sub-regulatory guidance reminds states that in the absence of a state-established and HHS-approved uniform age rating curve for the purpose of age rating in the individual and small group markets, a federal default standard will apply. The statute and final rule require that the premium rate charged by an issuer in the individual and small group market (for non-grandfathered plans) may vary by age, but not by more than a 3:1 ratio for adults. Moreover, the final rule defines, and the sub-regulatory guidance reiterates, the standard age bands for insurance rating purposes as follows...
Posted on April 10, 2013
This update to our previous Implementation Brief on states’ option to implement Medicaid coverage by enrolling beneficiaries into Qualified Health Plans sold in Exchanges examines Frequently Answered Questions on Medicaid and Premium Assistance (“FAQ”), released on March 29th by CMS. The FAQ answer some, but not all, questions raised by this approach to implementation of the ACA Medicaid expansion...
Categories: Health Insurance
Posted on April 4, 2013
This Implementation Brief examines current Administration policy regarding access to children’s oral health benefits among families who qualify both for Exchange coverage and for advance premium tax credits and cost-sharing reduction assistance. The Brief identifies an emerging set of policy issues that in turn may be creating a policy misalignment between children’s oral health coverage and the premium credits and...
Posted on April 3, 2013
The state health insurance exchanges are designed to provide consumers choices among pre-approved health plans that meet certain federal standards ranging from the provision of specific benefits to anti-discriminatory requirements for pre-existing health conditions. Only plans that meet these standards – the qualified health plans, or QHPs – will be allowed to participate in the exchanges. To further foster competition, the ACA also requires two QHPs participating in each exchange to be multi–state plans...
The QHP Certification Process in Federally-Facilitated Exchanges: Network Adequacy and Essential Community Providers
Posted on March 27, 2013
One of the more complex Affordable Care Act implementation questions involves the relationship between health insurance Exchanges and state departments of insurance around the issue of qualified health plan (QHP) certification. This relationship is discussed at some length in federal guidance published on March 1 2013, which offers the federal government’s latest thinking on how this relationship might work in states in which a federally funded Exchange (FFE) is operating, either with or without a Partnership agreement. As of March 2013, an FFE is expected to be operating in...
Posted on March 20, 2013
The ACA requires all individual and non-grandfathered group health plans to cover certain preventive services, including contraceptive services. This is an update to the March 2012 brief on Contraception Coverage within Required Preventive Services, and to the April 2012 update to that brief.
Posted on March 13, 2013
On February 25th, 2013, final regulations implementing the essential health benefit (EHB) provisions of the Affordable Care Act were published in the Federal Register (78 Fed. Reg. 12834-12872). The EHB rules, which amend 45 C.F.R., apply to all non-grandfathered individual and small group health plans sold after January 1, 2014, as well as Medicaid benchmark and benchmark-equivalent health plans. The EHB rules also apply to...
Posted on March 7, 2013
On February 28th, 2013, Politico reported that Arkansas Governor Mike Beebe had received approval “to take federal Medicaid expansion money and use it to buy private health coverage for low-income residents through the state’s insurance exchange.” This Implementation Brief explains the legal basis for this decision, as well as the issues that can be expected to arise in using this approach to coverage.
Posted on February 27, 2013
On February 6, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a new series of ACA-related Frequently Asked Questions (FAQs). The first two questions address the Basic Health Program (BHP). As described in an earlier Implementation Brief, the BHP was included in the ACA as a special state coverage option for low-income families and individuals. In answer to the question “When will the Basic Health Program be operational?”, CMS replied that the agency does not intend to propose implementing rules until sometime in 2013 and furthermore, that final rules will not be issued until 2014. The status of the Basic Health Program emerged as one of the subjects of a Senate Finance Committee’s ACA oversight hearing on February 14, 2013, during which Senator Maria Cantwell (D-WA), who sponsored the legislative amendment creating the BHP, questioned CCIIO Director Gary Cohen on the timing of BHP guidance.
Posted on February 7, 2013
This Update begins with a summary of federal policy guidance on health insurance Marketplaces that has been issued to date. It then presents in its entirety an interview with Gary Cohen, conducted by Professor Sara Rosenbaum of GW on January 29, 2013. The Update concludes with some observations about key issues that will arise as implementation of the federal Marketplace proceeds.
UPDATE: When Should Uninsured Family Members of Employees with Access to Affordable Self-Only Employer Coverage Qualify for Premium Tax Credits?
Posted on February 1, 2013
As noted in a previous Implementation Brief , the Affordable Care Act (ACA) allows for premium assistance through tax credits for the purchase of family coverage from qualified health plans sold through health insurance marketplaces. To be eligible for tax credits, individuals must not otherwise be “eligible for minimum essential coverage” and must have annual incomes of 100-400 percent of federal poverty level. With regard to individuals who are offered employer-sponsored coverage, the law states that in order to qualify for the premium tax subsidy, the employer-sponsored coverage must be deemed unaffordable, defined by the IRS as an employee contribution requirement for self-only coverage that exceeds 9.5 percent of household income. Although the ACA extends eligibility for assistance (based on the affordability test) to workers’ dependents, the remaining question, as noted in another earlier Brief, was whether uninsured family members of employees with access to affordable self-only employer coverage can qualify for a premium tax credit. The IRS answered that question...
Patient Centered Outcomes Research Institute: Final Rule on Calculation of Fees on Policies and Plans
Posted on January 30, 2013
The Patient-Centered Outcomes Research Institute (PCORI) was established under the Affordable Care Act (ACA) as a non-profit corporation to serve as a resource to patients, providers, purchasers and policymakers in making informed decisions about health outcomes, clinical effectiveness and appropriateness of medical treatments, items and services. The corporation is charged with advancing quality and evidence as to how health conditions can be prevented, diagnosed, treated, monitored and managed through research and evidence synthesis. The primary duties outlined in the ACA include identifying research priorities and setting an agenda for research provided through federal funding. PCORI is authorized to carry out a research project agenda through systematic reviews and...
Posted on January 25, 2013
On January 14, 2013, HHS issued a Notice of Proposed Rulemaking (NPRM) whose aim is to address a number of issues that arise at the intersection of the three principal federal “insurance affordability programs” established or modified under the Affordable Care Act (ACA): Medicaid; the Children’s Health Insurance Program (CHIP); and the advance premium tax credits and cost sharing reduction assistance available to individuals who apply for coverage in Exchanges. The proposed rules seeks to more closely align these pathways in several basic respects: the process...
Posted on January 23, 2013
On January 2, 2013, the Department of Treasury issued proposed regulations (78 Fed. Reg. 218) that describe in detail the standards that will be applied in determining which employers are covered by the Affordable Care Act’s “shared responsibility” requirements covering large employers. The proposed rules, which build on earlier guidance issued over the 2011-2012 time period, interpret §4980H of the Internal Revenue Code, as added by the ACA. This section provides...
Posted on January 16, 2013
Experts and stakeholders agree the current health care system is unsustainable. By 2020, health care spending will comprise almost 20% of the gross domestic product. Furthermore, an ever growing body of evidence clearly indicates that the system is not experiencing improvements in quality that are reflective of the cost growth. The Patient Protection and Affordable Care Act (ACA) takes significant strides towards the transformation of the American health care delivery system from a system that rewards volume to a system that rewards quality and value. The programs and initiatives...
Posted on January 3, 2013
On November 6, 2012, the Centers for Medicare and Medicaid Services (CMS) published final rules (77 Fed. Reg. 66670-66701) implementing an Affordable Care Act (ACA) provision whose purpose is to temporarily increase state Medicaid payments for primary care services. The ACA requires that state Medicaid agencies pay for primary care furnished by physicians in 2013 and 2014 at least...
Posted on December 20, 2012
As described in a previous Implementation Brief, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) generally prohibits group health plans and group health insurance issuers operating in the group health market from discriminating against similarly situated individuals with regard to premiums, benefits or eligibility based on a health factor. HIPAA recognized an exception...
Posted on December 19, 2012
This Update summarizes the CMS Frequently Asked Questions (FAQ) document issued on December 10, 2012.
Posted on December 10, 2012
The Patient Protection and Affordable Care Act (ACA) included health insurance market reforms designed to ensure that individuals and small businesses could not be denied coverage or be charged significantly higher premiums because of an individual’s health status. While some of the market reforms enacted in the ACA were designed to go into effect shortly after enactment (e.g., requiring issuers and employer-sponsored plans to cover adult children up to age 26 on a parent’s health plan, and limiting pre-existing condition exclusions) the most sweeping reforms...
Posted on December 5, 2012
Beginning January 1, 2014, millions of previously uninsured individuals will gain access to health insurance coverage under the Affordable Care Act (ACA). On November 20, 2012, the Obama Administration proposed a series of regulations that move the nation significantly toward full implementation. These proposed rules will be analyzed at greater length in coming GPS Implementation Brief updates. In the meantime, this overview summarizes the major federal implementation matters that the Administration has recently released or is expected to address in policy or program implementation in the coming weeks and months as the 2014 full implementation date approaches. Together, these matters address...
Essential Health Benefits Update: Proposed Regulations Implementing the ACA; and Application of the Proposed EHB Regulations to Medicaid Benchmark Plans
Posted on November 29, 2012
On November 26, 2012, the Obama Administration published a series of proposed rules implementing many of the Affordable Care Act’s (ACA) most important insurance reforms, including Health Insurance Market Rules and Rate Review (77 Fed. Reg. 70584), Nondiscriminatory Wellness Programs in Group Health Plans (77 Fed. Reg. 70620), and Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (77 Fed. Reg. 70644). In addition, the Administration issued informal guidance that add to and amplify on the provisions of the proposed rules. This Implementation Brief Update examines the proposed rule implementing the Act’s essential health benefits...
When Should Uninsured Family Members of Employees with Access to Affordable Self-Only Employer Coverage Qualify for Premium Tax Credits?
Posted on October 3, 2012
This Implementation Brief on premium tax credits examines the question of how the Affordable Care Act (ACA or the Act) addresses the problem that arises when low- and moderate-income employees have affordable “self-only” employer coverage, but face prohibitively high costs for family coverage, well beyond levels considered “affordable” under the Act. Coverage for a full family is extremely expensive: according to the Kaiser Family Foundation, the average 2012 cost of family coverage approaches $16,000, placing unsubsidized family benefits beyond the reach of all but affluent families. Kaiser further reports that while...