Comments on the November 30, 2013 proposed rule are due March 3, 2014.

Comments on the collection of information for the proposed rule are due January 31, 2014.

Read the rule (which was published in the Federal Register on December 2, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-12-02/pdf/2013-28409.pdf

For additional information on the Net Investment Income Tax, visit: http://www.irs.gov/uac/Newsroom/Net-Investment-Income-Tax-FAQs

11/25/13 HHS issued a proposed rule called "Patient Protection and Affordable Care Act: HHS Notice of Benefit and Payment Parameters for 2015." The proposed rule sets forth payment parameters applicable to the 2015 benefit year and oversight provisions related to the premium stabilization programs. The rule proposes standards related to the advance payments of the premium tax credit, cost-sharing reductions, composite rating, privacy and security standards, the annual open enrollment period for 2015, the actuarial value (AV) calculator, the annual limitation on cost sharing for stand-alone dental plans, patient safety, and the Small Business Health Options Program (SHOP).

Beginning October 1, 2013, qualified individuals and qualified employees could purchase private health insurance coverage through Exchanges (Marketplaces) for January 1, 2014 effective dates. 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. §1311(b)(1)(B) also requires that the Small Business Health Options Program (SHOP) assist qualified small employers in facilitating the enrollment of their employees in qualified health programs (QHPs) offered in the small group market. QHPs are health plans that have been certified by an Exchange, provide essential health benefits ("EHB", §1301) and follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts).

In 2014, HHS will implement the premium stabilization programs, which will stabilize premiums in the individual and small group markets and minimize the effects of adverse selection that may occur as insurance reforms and the Exchanges launch. These programs include transitional reinsurance (§1341), temporary risk corridors programs (§1342), and a permanent risk adjustment program (§1343) to provide payments to health insurance issuers that cover higher-risk populations and to more evenly spread the financial risk borne by issuers. The transitional reinsurance program and the temporary risk corridors program, which begin in 2014, are designed to provide issuers with greater payment stability as insurance market reforms are implemented. The reinsurance program will reduce the uncertainty of insurance risk in the individual market by partially offsetting risk of high-cost enrollees. The risk corridors program, which is a federally administered program, will protect against uncertainty in rates for qualified health plans by limiting the extent of issuer losses and gains.

Under the rule, HHS proposes changes to the risk corridor and reinsurance programs. HHS proposes to decrease the reinsurance attachment point from $60,000 to $45,000 for the 2014 benefit year due to updated estimates that allow for greater payments from the contribution fund. HHS also proposes to modify the agency's contribution collection schedule for the reinsurance program. Under the rule, HHS proposes a change in small group participation in the risk adjustment and risk corridor programs, stating that a plan be classified as a small group plan (for purposes of risk adjustment) according to the employee counting method applicable under state law (as long as the method accounts for part-time employees).

The ACA sets limits on cost sharing to protect individuals from excessive out-of-pocket expenses. Beginning in 2014, plans that cover EHB must cover a certain percentage of costs, known as AV or "metal levels."  AV is calculated as the percentage of total average costs for covered benefits that a plan will cover and helps consumers distinguish the level of coverage offered by different health plans. To streamline and standardize the calculation of AV for health insurance issuers, HHS provided a AV calculator, which issuers use to determine health plan AVs based on a national, standard population. The tool allows users to measure the AV of health plans and compliance with AV standards established under ACA §1302(d). In the rule, HHS proposes to update the AV Calculator and Methodology for 2015 and proposes parameters under which the AV Calculator could be updated in future plan years.

Comments are due December 26, 2013.

Read the proposed rule (which was published in the Federal Register on December 2, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-12-02/pdf/2013-28610.pdf

The proposed 2015 AV calculator and methodology can be accessed at:

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/index.html#Premium Stabilization Programs

11/22/13 CMS/HHS issued an ACA-related final rule called "Medicare and Medicaid Programs: Home Health Prospective Payment System Rate Update for CY 2014, Home Health Quality Reporting Requirements, and Cost Allocation of Home Health Survey Expenses." The rule implements portions of ACA §3131 and 3401.

To qualify for the Medicare home health benefit, a Medicare beneficiary must be homebound and under the care of a physician; have an intermittent need for skilled nursing care, or need physical therapy, or speech-language pathology; or continue to need occupational therapy. Medicare pays home health agencies through a prospective payment system (PPS) that pays higher rates for services furnished to beneficiaries with greater needs. Payment rates are based on relevant data from patient assessments conducted by clinicians as currently required for all Medicare-participating home health agencies. Home health payment rates are updated annually by the home health payment update percentage.

Beginning in CY 2014, as required by the ACA, the annual final rule applies an adjustment to the national, standardized 60-day episode rate that reflects factors such as changes in the number of visits in an episode, the mix of services in an episode, the level of intensity of services in an episode and the average cost of providing care per episode. The final rule also updates the national per-visit rates used to calculate low utilization payment adjustments (LUPAs) and outlier payments under the Medicare prospective payment system for home health agencies. These changes would apply to services furnished on or after January 1, 2014.

Read the rule (which was published in the Federal Register on December 2, 2013) at:

http://www.gpo.gov/fdsys/pkg/FR-2013-12-02/pdf/2013-28457.pdf

11/22/13 CMS/HHS issued an ACA-related final rule called "Medicare Programs: End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies." The rule implements portions of ACA § 3401 and 3014.

The annual final rule updates and revises the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2014. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2016 and beyond. The changes areapplicable to services furnished on or after January 1, 2014.

In addition, the final rule clarifies the grandfathering provision related to the 3-year minimum lifetime requirement for Durable Medical Equipment (DME), and provides clarification of the definition of routinely purchased DME. The final rule also makes a few technical amendments and corrections to existing regulations related to payment for durable medical equipment, prosthetics, orthotics, and supplies, items and services.

Read the rule (which was published in the Federal Register on December 2, 2013) at:

http://www.gpo.gov/fdsys/pkg/FR-2013-12-02/pdf/2013-28451.pdf

11/22/13 HHS/CMS published a notice under the Paperwork Reduction Act of 1995 (PRA) seeking comments on proposed information collection activities related to the annual medical loss ratio (MLR) and rebate calculation report and MLR rebate notices under ACA §10101.

The ACA's MLR rules establish the minimum dollar percentage that health insurance companies must spend of consumers' health insurance premiums on medical care and quality improvement activities, rather than on salaries, overhead or marketing. Starting with the 2011 reporting year, the ACA required insurance companies in the individual and small group markets to spend at least 80% of collected premium dollars on medical care and quality improvement activities; insurance companies in the large group market are required to spend at least 85%. Under the MLR rules, insurance companies that do not meet the MLR standard are required to provide rebates to their consumers. Rebates must be paid by August 1st each year and insurers made the first round of rebates to consumers in 2012. Insurance companies must report their MLR data (including information about any rebates it must provide, on an HHS form, for each state in which the issuer conducts business) to HHS on an annual basis. According to HHS, the data will allow residents of every state to have information about the value of the health plans offered by insurance companies in their state.

Based on past experience with MLR data collection and the evaluation process,

HHS is updating the agency's projections regarding the numbers of submissions, rebates, and rebate notices.

Comments are due January 21, 2014.

Read the notice at: http://www.gpo.gov/fdsys/pkg/FR-2013-11-22/pdf/2013-28049.pdf (See item #5) 

Prior guidance can be found at: http://www.hhs.gov/healthcare/index.html 

News

11/26/13 The U.S. Preventive Services Task Force (USPSTF) issued a final recommendation statement on screening for oral cancer in adults without signs or symptoms of oral cancer who are seen by primary care providers. The Task Force concluded that there is a lack of current concrete evidence to recommend that primary care clinicians perform screening for oral cancer on all adult patients. As a result, the USPSTF issued an "I" recommendation statement, which reflects that there is insufficient evidence for the USPSTF to make a recommendation. The recommendation applies to adults without signs or symptoms of oral cancer and is a recommendation about the practices of primary care professional; it does not apply to specialists (such as dentists and oral health professionals).

According to the Task Force, oral cancer (also known as oral cavity cancer) is a type of head and neck cancer that is found in the mouth and lips. The primary screening test for oral cancer is to look inside and feel a patient's mouth, face, and neck for potentially cancerous lesions, lumps, or other abnormalities. The screening can be performed by a primary care clinician, dentist, or other dental care professional.

The USPSTF's evidence review found that, although it is unclear whether or not screenings in primary care settings are constructive, adults can reduce their risk of oral cancer by avoiding smoking (and all forms of tobacco) and limiting their alcohol intake. Additionally, the USPSTF found that patients with lumps, bumps, or lesions in their mouths or on their lips should seek an examination by a health care professional.

Although screening for oral human papillomavirus (HPV) was not considered for this recommendation, the Task Force recognizes that it is a growing risk factor for developing oropharyngeal cancer. Oropharyngeal cancer is a type of head and neck cancer usually located farther in the back of the mouth and throat and may be tough to visualize in a primary care setting. According to the USPSTF, there has been limited research done on the relationship between oropharyngeal cancer and HPV, ways of preventing HPV infection, and new screening techniques for HPV-related head and neck cancer. As a result, the USPSTF emphasizes the need for additional research in these areas.

The USPSTF is an independent panel of non-federal government experts that conduct reviews of scientific evidence of preventive health care services. The USPSTF then develops and publishes recommendations for primary care clinicians and health systems in the form of recommendation statements. As part of their recommendations process, the USPSTF will assign definitions to the services they review based on the certainty that a patient will receive a substantial benefit from receiving the benefit. Services that are graded "A" and "B" are highly recommended and the USPSTF believes there is a high certainty that patient will receive a substantial or moderate benefit. 

Under ACA §1001, all of the recommended services receiving grades of "A" or "B" must be provided without cost-sharing when delivered by an in-network health insurance provider in the plan years (or, in the individual market, policy years) that begin on or after September 23, 2010. Because the final recommendation on primary care clinicians' screening asymptomatic adults for oral cancer received an "I" rating, the screenings will not be required to be covered without cost-sharing under the ACA.

Read the final recommendation statement at: http://www.uspreventiveservicestaskforce.org/uspstf13/oralcan/oralcanfinalrec.htm

Learn more about preventive services covered under the ACA at: HHS.Gov

Learn more about the USPSTF at: http://www.uspreventiveservicestaskforce.org/

11/22/13 HHS announced that the deadline for enrolling in a qualified health plan (QHP) through an Exchange for coverage effective January 1, 2014, had been delayed from December 15, 2013 to December 23, 2013. Consumers must pay their first premium by December 31, 2013 for health insurance coverage that begins on January 1, 2014.

Beginning October 1, 2013, qualified individuals and qualified employees could purchase private health insurance coverage through Exchanges (Marketplaces) for January 1, 2014 effective dates. 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.

Learn more about Exchange open enrollment at: Healthcare.Gov 

Commonwealth of MA News

Integrating Medicare and Medicaid for Dual Eligible Individuals

Implementation Council Meeting

Friday, December 20, 2013

1:00-3:00 PM

State Transportation Building, Conference Room 1-3

10 Park Plaza

Boston, MA

Meetings of the Implementation Council are open to stakeholders and members of the public with an interest in One Care. Reasonable accommodations will be made for participants who need assistance. Please send your request for accommodations to Donna Kymalainen at Donna.Kymalainen@state.ma.us.