Guidance
3/4/13 CMS/CCIIO issued a draft letter to issuers on Federally-facilitated and State Partnership Exchanges. The letter provides Qualified Health Plan (QHP) issuers in Federally-facilitated Exchanges (FFE) and Federally-facilitated SHOPs (FF-SHOP), including State Partnership Exchanges, with operational and technical guidance to help them successfully participate in Exchanges.
The ACA established Affordable Insurance Exchanges (§1311(b)) to provide individuals and small business employees with access to health insurance coverage beginning January 1, 2014. States have the option of running either a State-Based Exchange or a State-Federal Partnership Exchange. Under the State Partnership Exchange (§1311), states operate their Exchangesin partnership with the federal government. This is an option provided to states that want to manage part of the Exchange in 2014, allowing states to make key decisions, serve as the primary points of contact for issuers and consumers and tailor the marketplace to local needs and market conditions. If a state does not choose either option, a Federally-Facilitated Exchange will operate in that state (§1321).
To date, 18 states including Massachusetts have been conditionally approved to run State-Based Exchanges. 3 states have been conditionally approved to run State Partnership Exchanges. Conditional approval reflects the progress that states have made and the expectation that enrollment in the Exchange will begin in October 2013 and that coverage through the Exchange for consumers and small businesses will begin in 2014.
Read about Federally-Facilitated Exchange Exchanges at: http://cciio.cms.gov/resources/factsheets/ffe.html
Read about State Partnership Exchanges at: http://cciio.cms.gov/resources/files/partnership-guidance-01-03-2013.pdf
Learn more about Exchanges and see a list of states with conditional approvals at: http://cciio.cms.gov/resources/factsheets/state-marketplaces.html
Comments on the draft letter are due March 15, 2013.
Read the draft letter at: http://cciio.cms.gov/resources/files/issuer-letter-3-1-2013.pdf
3/1/13 IRS issued a proposed rule and a notice of public hearing regarding "Health Insurance Providers Fee." The regulations provide guidance on the annual fee imposed on covered health insurance plans engaged in the business of providing insurance for United States health risks under ACA §9010. The ACA defines a United States health risk as the health risk of an individual who is a United States citizen, a resident of the United States or located within the United States.
Beginning in 2014, each health insurance plan with aggregate net premiums exceeding over $25 million is liable for the annual fee due by September 30th of each fee year. The annual fee for each entity is determined by the ratio of the plan's net premiums for the previous calendar year and the aggregate net premiums of all qualified health insurance plans for the previous calendar year. Health plans that have net premiums that exceed $25 million but are less than $50 million will have 50% of their net premiums taken into account for this calculation. Entities with net premiums over $50 million will have 100% of their net premiums taken into account for this calculation. The regulation establishes the aggregated annual fee for all entities at $8 billion for 2014, $11.3 billion for 2015 and 2016, $13.9 billion for year 2017, and $14.3 billion for 2018. The regulation also lists exemptions from the fee which include self-insured employers, government entities, certain nonprofit corporations and certain voluntary beneficiary associations.
The IRS is holding a public hearing on the proposed rule on June 21, 2013. For additional information on the hearing please read the notice.
Comments are due June 3, 2013.
Read the rule and notice (which were published in the Federal Register on March 4, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-03-04/pdf/2013-04836.pdf
2/28/13 DOL/EBSA announced final rules that grant the Secretary of Labor additional enforcement authority to pursue fraud in certain employer-based healthcare plans known as multiple-employer welfare arrangements (MEWAs). The final rules implement ACA §6605 and §6606 and protect employers, health care providers and workers from mismanaged MEWAs that fail to pay legitimate claims or embezzle premium dollars.
Designed to give small employers access to low cost health coverage on terms similar to those available to large employers, MEWAs are arrangements that provide health and welfare benefits to two or more unrelated employers. However, DOL says that fraud has been prevalent in MEWAs and the plans have been able to circumvent state laws that require plans to keep enough funds readily available to pay claims.
The first final rule issued is "Ex Parte Cease and Desist and Summary Seizure Orders - Multiple Employer Welfare Arrangements." Under the final rule, the Secretary can issue a cease and desist order, ex parte (without prior notice or hearing), if it appears that a MEWA is fraudulent, creates an immediate danger to public safety or welfare, or can be reasonably expected to cause significant or imminent public injury. The rule also authorizes the Secretary to issue a summary seizure order of the MEWA's assets order if it appears that a MEWA is financially unstable.
Previously, DOL needed a court order when it identified possible fraud which allowed potential delinquent MEWAs additional time to further deplete their plans' reserves. The new rules would allow enforcement without prior notice or hearing so that regulators could stop operations and freeze any remaining funds before administrators can lose or disappear with them.
Read the final rule (which was published in the Federal Register on February 29, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-03-01/pdf/2013-04862.pdf
The second final rule issued is "Filings Required of Multiple Employer Welfare Arrangements and Certain Other Related Entities." The final rule implements reporting requirements for MEWAs and certain other entities that offer or provide health benefits for employees of two or more employers. The rule amends existing reporting rules to incorporate new requirements enacted as part of §6606 and to clearly address the reporting obligations of MEWAs that are ERISA plans. The Employee Retirement Income Security Act of 1974 (ERISA) protects the assets of employees so that funds placed in retirement plans during their careers will be there when they retire. ERISA is a federal law that sets minimum standards for pension plans in private industry. Although ERISA does not require any employer to establish a pension plan it requires that those who establish plans must meet certain minimum standards. The final MEWA regulations require MEWAs to register with DOL before establishing operations in a new state.
Read the final rule (which was published in the Federal Register on February 29, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-03-01/pdf/2013-04863.pdf
DOL also published various notices making changes to the various forms used for reporting.
Read the DOL fact sheet to learn more at: http://www.dol.gov/ebsa/newsroom/fsMEWA-ACA.html
2/28/13 IRS published a correction to the proposed rules "Coverage of Certain Preventive Services Under the Affordable Care Act," that were published in the Federal Register on February 6, 2013. The correction makes clarifying and technical changes to the proposed rules.
The proposed rule implements provisions under ACA §1001(2713) that provide coverage for preventive care that includes contraceptive services for women without cost sharing, while respecting the concerns of certain religious organizations, including eligible organizations that are religious institutions of higher education, that establish or maintain or arrange health coverage. Under §1001(2713) non-exempt, non-grandfathered group health plans are required to provide such coverage. Group health plans of "religious employers" are exempted from the requirement to provide contraceptive coverage if they have religious objections to contraception.
Read the correction at: http://www.gpo.gov/fdsys/pkg/FR-2013-02-28/pdf/2013-04608.pdf
2/22/13 Occupational Safety and Health Administration (OHSA)/
Department of Labor (DOL) issued an interim rule and request for comments called, "Procedures for the Handling of Retaliation Complaints Under Section 1558 of the Affordable Care Act." The rule implements the whistleblower protection statute under ACA §1558 that provides protection to employees from retaliation by an employer for reporting potential violations of the consumer protections under Title I of the ACA (such as the prohibition on denials of insurance due to pre-existing conditions) or its affordability assistance provisions. Employees who receive a tax credit or cost-sharing reduction as a result of participating in a Health Insurance Exchange and/or enrolling in a qualified health plan (QHP) are also protected. Under the rule, OHSA proposes procedures and timeframes for the handling and investigation of retaliation complaints necessary to govern whistleblower investigations conducted under the whistleblower statute.
The ACA contains various provisions to make health insurance more affordable and accountable to consumers. The ACA established Affordable Insurance Exchanges (§1311(b)) to provide individuals and small business employees with access to health insurance coverage beginning January 1, 2014, where low and moderate income Americans will be eligible for premium tax credits (§1401, §1411) to make purchasing a health plan more affordable by reducing out-of-pocket premium costs. QHPs are health plans that have been certified by an Exchange, provide essential health benefits (§1301) and follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts). Title I includes insurance company accountability requirements, such as guaranteed availability of coverage (§1201) or exclusions due to pre-existing conditions (§1201). Title I also includes requirements for certain employers. Starting in 2014, under Section 4980H which was added to the IRS Code by ACA §1513, if employers with 50 or more full-time employees do not offer affordable health coverage that provides a minimum level of coverage (§1501) to their full-time employees, they may be subject to an Employer Shared Responsibility payment if at least one of their full-time employees receives a premium tax credit (§1401, §1411) for purchasing individual coverage on one of the Health Insurance Exchanges. For more information on the Shared Responsibility provisions, read the Q & A's at: IRS.Gov
Comments are due April 19, 2013.
Read the press release at: OSHA.Gov
Read the interim final rule and request for comments (which was published in the Federal Register on February 27, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-02-27/pdf/2013-04329.pdf
2/22/13 HHS/CMS issued a final rule called "Patient Protection and Affordable Care Act; Health Insurance Market Rules; Rate Review." The final rule implements key portions of the ACA designed to prevent insurance companies from discriminating against people with pre-existing conditions and to prevent insurers from charging discriminatory rates to individuals and small employers based on factors such as health status or gender (§1201). The final rule also extends additional affordable coverage options to young adults under catastrophic health plans (§1302). The final rule implements five provisions that, effective for health plan years beginning in January 2014, are applicable to non-grandfathered health plans.
Provisions of the final rule implement ACA policies related to: fair health insurance premiums (§1201), guaranteed availability of coverage (§1201), guaranteed renewability of coverage (§1201), requirements that plans create a single risk pool in the individual and small group market (§1312), and enrollment in catastrophic plans (§1302). It also amends the premium review standards for health insurance issuers and states regarding reporting, utilization, and collection of data and revises the timeline for states to propose state-specific thresholds for premium rate review and approval by CMS under §1003.
Read the proposed rule (which was published in the Federal Register on November 26, 2012) at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-26/pdf/2012-28362.pdf
Read the final rule (which was published in the Federal Register on February 27, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-02-27/pdf/2013-04335.pdf
2/22/13 The HHS Assistant Secretary for Planning & Evaluation (ASPE) issued a report on the rate review program under §1003. The analysis shows that health insurers have been requesting fewer rate increases over 10% since the rate review program went into effect in September 2011. The data shows that in 2010, 75% of state filings to increase rates in the individual market were for increases of 10% or more. Preliminary 2013 data shows that only 14% of rate filings in that year requested an increase of 10% or more.
The rate review program under §1003 requires that insurers seeking rate increases of 10% or more for non-grandfathered plans in the individual and small group markets publicly and clearly disclose the proposed increases and the justification for them. Such increases are reviewed by either state or federal experts (in states that do not have a rate review program deemed effective by HHS) to determine whether they are unreasonable. Although the ACA does not grant HHS the authority to block a proposed rate increase, companies whose rates have been determined unreasonable must either reduce their rate hikes or post a justification on their website within 10 days of the rate review determination. CMS determined that both the individual and small-group markets in Massachusetts meet standards under §1003 and that the Commonwealth does have an effective rate review process.
Prior guidance can be viewed at www.healthcare.gov
News
2/20/13 Department of Labor (DOL) posted the 12th set of FAQs regarding implementation of various provisions of the ACA. The FAQs have been prepared by the DOL, HHS, and the Treasury. This set of FAQs addresses the limitations on cost-sharing under the ACA and the coverage of preventive services.
The ACA provides that a group health plan must ensure that any annual
cost-sharing imposed on beneficiaries under the plan does not exceed the limitations provided for under ACA §1302(c)(1) and §1302(c)(2). §1302(c)(1) limits out-of-pocket maximums and §1302(c)(2) limits deductibles for employer-sponsored plans. The February 25, 2013 "Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation" final rule outlines health insurance issuer standards for essential health benefits (EHB), a core package of benefits that health insurance issuers must cover both inside and outside the Health Insurance Exchanges as required by ACA §1302. Effective January 1, 2014, all plans sold in the exchanges and through the small group and individual markets must be equal in scope to the benefits covered by a typical employer plan and offer an EHB package of medical services and treatments in ten prescribed categories. Affordable Insurance Exchanges (§1311(b)) will provide individuals and small business employees with access to health insurance coverage beginning January 1, 2014. Under the final rule and as required by §1302, the EHB package must also include cost-sharing limits and adhere to actuarial value (AV) requirements, a defined percentage of costs to be covered by the plan. The final rule also finalizes policies related to qualified health plans (QHPs) that will be offered through the Health Insurance Exchanges. QHPs are health plans that have been certified by an Exchange, provide essential health benefits (§1301) and follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts).
The FAQ's also address the interim final regulations (published November 17, 2010) which require non-grandfathered group health plans and health insurance coverage offered in the individual or group market to provide benefits for and prohibit the imposition of cost-sharing requirements with respect to certain preventive services. The FAQs also address the notice of proposed rulemaking (NPRM) called "Coverage of Certain Preventive Services Under the Affordable Care Act" NPRM that exempts certain non-grandfathered, non-profit religious organizations from the requirement to cover the recommended contraceptive services. The proposal implements provisions under ACA §1001(2713) that provide women with coverage for preventive care that includes contraceptive services without cost sharing, while respecting the concerns of certain religious organizations. For information about women's access to preventive coverage visit: Healthcare.Gov
Read the 12th set of FAQ's at:
http://www.dol.gov/ebsa/faqs/faq-aca12.html
EOHHS News
2/28/13 The Office of Medicaid submitted comments to HHS/CMS on the proposed single streamlined application under ACA §1413 that will be used for eligibility determinations for Affordable Insurance Exchanges, Medicaid and the Children's Health Insurance Program beginning in the fall of 2013. States may also submit a request to the HHS Secretary for approval to use an alternative application.
The individual application is a single point of entry to purchase private insurance on the Exchange and assess eligibility for assistance including, Medicaid, CHIP, and premium tax credits. The ACA established Affordable Insurance Exchanges (§1311(b)) to provide individuals and small business employees with access to health insurance coverage beginning January 1, 2014, where low and moderate income Americans will be eligible for premium tax credits (§1401, §1411) to make purchasing a health plan more affordable by reducing out-of-pocket premium costs.
CMS issued model applications and documentation for individuals and small businesses and model SHOP applications for both employers and employees were posted for comment. CMS sought comment on both the paper and online applications. CMS released two videos of the application being completed in order to demonstrate how users can interact with the online application; one follows a family of three and the other an individual.
The application materials are available under the Paperwork Reduction Act (PRA) listing "Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Affordable Insurance Exchanges, Medicaid and Children's Health Insurance Program Agencies" at: CMS.Gov
The comment period has closed but a link to the January 29, 2013 Federal Register notice about the application can be read at: http://www.gpo.gov/fdsys/pkg/FR-2013-01-22/pdf/2013-00659.pdf
The Massachusetts comment letter can be read online at the Massachusetts national health reform website under the State and Federal Communications section at: Mass.Gov
Upcoming Events
Money Follows the Person (MFP) Stakeholder Meeting
March 19, 2013, 10:00 AM - 11:30 AM
State Transportation Building
10 Park Plaza
Boston, MA
Please contact MFP@state.ma.us if you would like to attend the meetings.
Requests for reasonable accommodations should be sent to MFP@state.ma.us. Although an RSVP is not required, it is appreciated.
