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Chris Cadena is an associate in Crowell & Moring's San Francisco office and practices in the Litigation and Health Care groups.

Chris earned his J.D. in 2012 from the UCLA School of Law, where he was the chief managing editor of the Chicano–Latino Law Review and a writing advisor for the school's Lawyering Skills course. While attending law school, Chris was an extern for the California Department of Justice, Attorney General's Office in Oakland. Chris graduated with honors from UC Berkeley, earning his B.A. in history.

On April 6, the Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule to implement the 2008 Mental Health Parity and Addiction Equity Act (“MHPAEA”) for coverage offered by Medicaid Managed Care Organizations (“MCOs”), Medicaid Alternative Benefit Plans (“ABPs”) and the Children’s Health Insurance Program (“CHIP”).  MHPAEA requires group health plans and health insurance issuers to ensure that financial requirements or treatment limitations applicable to mental health and substance-use disorder (“MH/SUD”) benefits are comparable to, and are applied no more stringently than, the same financial requirements or treatment limitations applied to medical and surgical (“M/S”) benefits.  Interim final regulations implementing MHPAEA for commercial plans were jointly issued by the Departments of Health and Human Services, Labor and the Treasury (collectively, the “Departments”) in February 2010, and final regulations were jointly issued by the Departments in November 2013 (hereinafter, the “Joint Regulations”).

Since the passage of the Mental Health Parity Act of 1996, parity mandates have been enacted that reach most types of health care coverage, although what is required by “parity” laws can vary greatly.  In 2001, the Federal Employees Health Benefits Program implemented parity for in-network mental health and substance use disorder benefits. MHPAEA was enacted in 2008 to extend the reach and scope of parity (to include, among other factors, substance-use disorder benefits) in large group coverage.  The Affordable Care Act’s Essential Health Benefits requirements now require most individual and small group coverage to include mental health and substance use disorder benefits, and these benefit must be provided in compliance with MHPAEA.  If finalized, this CMS proposed rule would further clarify the application of mental health parity requirements, in this case to Medicaid programs.

Continue Reading CMS Proposed Rule Implements Mental-Health Parity Requirements for Medicaid Managed Care and CHIP Plans

According to a new study focusing on consumer information, nearly 25 percent of group health plans provided through Affordable Care Act (“ACA”) exchanges may be violating federal mental-health parity laws.

The study was led by associate professor Colleen Barry of the Johns Hopkins Bloomberg School of Public Health, and is published in the current issue of Psychiatric Services. To conduct the study, Barry and her colleagues reviewed benefit brochures offered in two state-run exchanges during the first ACA enrollment period between 2013 and 2014.

The study alleges two significant problems. First, according to the study plans in the exchange often had financial disparities. For example, the study found that plans would include different co-pays for mental-health and substance-use disorder services from medical/surgical services. Second, according to the study some mental-health and substance-use disorder services had more stringent “prior authorization” requirements than their medical/surgical counterparts. These disparities, the report suggests, can dissuade people from selecting more expensive plans with more generous mental-health and substance-use-disorder benefits. According to the study, because mental-health and substance-use disorder services are often more expensive than medical/surgical services, insurers may benefit when consumers are dissuaded from joining plans with more generous mental-health and substance-use disorder benefits.

Continue Reading Study Suggests Many ACA Exchange Plans Violate Federal Parity Laws

On March 4, 2015, The U.S. Government Accountability Office (GAO) released a report on the troubled rollout of Healthcare.gov. The GAO concluded that weak oversight by the federal Office of Management and Budget (OMB) may have contributed to the technology problems associated with the Healthcare.gov project. In one example of poor oversight, the GAO noted that the Department of Health and Human Services (HHS) uses Healthcare.gov for public exchange enrollment in certain states. But the HHS Chief Information Officer insufficiently oversaw the project and did not play a direct role in managing HHS Information Technology (IT).

The GAO report also found that OMB failed to enforce its own IT standards. OMB was tasked with closely monitoring the Healthcare.gov project, yet the report found that “involvement in overseeing the development efforts of HealthCare.gov and its supporting systems was limited prior to the initial launch in October 2013.” OMB’s oversight of the project did not include a thorough review, despite the fact that Healthcare.gov was flagged as a high-risk project and OMB had notice of technical problems seven months before the October 2013 website launch.

The full text of the GAO Report can be found here.

On December 12, 2014, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that would broaden rights for same-sex spouses at US hospitals. The proposed rule is aimed at “ensur[ing] that same-sex spouses in legally-valid marriages are recognized and afforded equal rights in Medicare and Medicaid participating facilities.”

In its 2013 decision United States v. Windsor, The Supreme Court struck down part of the Defense of Marriage Act that governed federal benefits. CMS proposes to make certain regulations consistent with the Windsor decision by revising applicable conditions of participation for providers, conditions for coverage for suppliers, and requirements for long-term care facilities. The proposed rule would revise certain definitions and patient’s rights provisions to ensure that terms including “spouse” and “representative” include same-sex spouses for the purposes of healthcare visitation. In the context of hospice care, the definition of “representative” would be revised to allow a same-sex spouse to authorize or terminate medical care on behalf of a terminally ill patient who is incapacitated.

 

On September 2, 2014, the Centers for Medicare & Medicaid Services (CMS) announced a Final Rule specifying enrollment notice requirements and re-enrollment options for plans offered through the Exchange in 2015. Regarding notice requirements, the Final Rule states that consumers in the Exchange will receive notices from the marketplace before open enrollment begins that explain the auto-enrollment process and how consumers can return to the Marketplace to verify whether they qualify for more financial assistance. Insurance companies will also notify consumers about the 2015 premium and the amount the consumer might save on their monthly bill with a premium tax credit.

The Final Rule also indicates that if consumers do nothing as part of the renewal process, they generally will be auto-enrolled in the same plan with the same premium and other applicable financial assistance as the 2014 plan year. CMS explains that this Final Rule is intended to provide Exchange consumers with a simple way to keep their current health insurance plan and encourage consumers to return to the Marketplace.

The full text of the Final Rule, which is effective in October 6, 2014, can be found here.

On June 20, 2014, Health and Human Services Secretary Sylvia Burwell announced management changes intended to improve the implementation of the Affordable Care Act. The changes are being implemented in response to the rollout of Healthcare.gov and recommendations submitted to the Secretary. Andy Slavitt will join the Centers for Medicare and Medicaid Services (CMS) as a new operations-focused Principal Deputy Administrator for policy and operational coordination. CMS will also seek a single Marketplace CEO and a new Marketplace CTO. These individuals will be accountable for policy development and technical operations of the federal Health Insurance Marketplace.

On March 17, 2014, the Centers for Medicare and Medicaid Services (CMS) issued for public inspection a proposed rule regarding the Exchange and Insurance Market Standards for 2015 and later years. The proposed rule addresses requirements under the Affordable Care Act (ACA) applicable to insurance issuers, exchanges, and other entities.

Continue Reading CMS Issues Proposed Rule Regarding Exchange and Insurance Market Standards for 2015 and Beyond

The Centers for Medicare and Medicaid Services (CMS) published its final Notice of Benefit and Payment Parameters for 2015 (Final Rule), altering parameters for premium stabilization programs established by the Affordable Care Act (ACA). The Final Rule primarily concerns the risk adjustment, reinsurance, and risk corridors programs.

The Final Rule completes provisions related to the advance payments of the premium tax credit, cost sharing reductions, and premium stabilization programs, including certain oversight provisions for the premium stabilization programs and key payment parameters for the 2015 benefit year. Using the methodology set forth in the 2014 payment notice, the Final Rule establishes a 2015 uniform reinsurance contribution rate of $44 annually per capita, as well as the 2015 uniform reinsurance parameters—a $70,000 attachment point, a $250,000 reinsurance cap, and a 50 percent coinsurance rate. The Final Rule also decreases the attachment point from $60,000 to $45,000. To maximize the impact of the reinsurance program, CMS provides that for reinsurance contributions collected for a benefit year exceeding total requests for reinsurance payments for the benefit year, CMS will increase the coinsurance rate on its reinsurance payments up to 100 percent.

Continue Reading CMS Issues Final Notice Regarding Payment Parameters for 2015

On February 6, 2014, the Centers for Medicare and Medicaid Services (CMS) released a new rule, effective April 7, 2014, amending the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations and the HIPAA Privacy Rule. The new rule specifies that, at the request of a patient, laboratories subject to CLIA may provide the patient, or the patient’s personal representative, with copies of completed test reports that can be identified as belonging to the patient.

Previously, CLIA regulations authorized labs to release test results only to a person authorized under state law to order or receive results (usually only a health care provider), the person responsible for using the test results, or the lab that requested the test. The Final Rule amends these limitations to allow the lab to provide the test results directly to patients and their personal representatives. The Final Rule also amends the Heatlh insurance Portablitiy and Accountability Act Privacy Rule’s provisions on a patient’s right to access protected health information in a designated record set by removing the exceptions for CLIA-certified or exempt.

CMS states that the changes to the CLIA regulations and the HIPAA privacy rule provide individuals with a greater ability to access health information.

The full text of the rule can be found here.

On September 19, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule regarding financial integrity and oversight standards with respect to Affordable Care Act Insurance Exchanges.

As of January 1, 2014, Affordable Insurance Exchanges (“Exchanges”) can make available private health insurance coverage for qualified individuals and employers. This proposed rule outlines standards for financial integrity and oversight for Exchanges, as well as for issuers in Federally-facilitated Exchanges (FFEs), and States. The rule also addresses the risk adjustment and transitional reinsurance programs. The proposed rule details accounting requirements for State-operated reinsurance and risk adjustment programs, and includes requirements relating to summary reports and external audits for such programs. Additionally, the proposed rule offers standards for special enrollment periods, survey vendors, issuer participation in an FFE, and States’ operations of a Small Business Health Options Program (SHOP). CMS notes that, while the proposed rule would become effective in January 2014, CMS does not believe affected parties will have difficulty complying with the new provisions because most of the proposed requirements are based on existing standards within the private market, and were previously proposed and discussed in regulatory guidance.