C&M Health Law

C&M Health Law

Analysis, commentary, and the latest developments in health care law and policy

Category Archives: Exchanges

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Upcoming Webinar: Looking Back & Looking Beyond – The First 100 Days in Health Care Policy

Posted in Events, Exchanges, Fraud, Waste & Abuse, Health Care Reform & ACA, Medicaid, Medicare
On Tuesday, April 18, 2017, our Health Care Group will hold a webinar on the health care policy and transition challenges still at play as the Trump Administration nears the end of its 100 days in power.  During the webinar, participants will hear important insights and predictions on what a Trump-led Executive Branch will mean… Continue Reading

Waiting for the Supremes: High Court’s Decision in Gloucester County to Determine Validity of ACA Section 1557 Gender Identity and Transgender Services Rules

Posted in Exchanges, Health Care Reform & ACA
Two district courts[1] have recently stayed cases alleging that sex discrimination under ACA Section 1557 includes discrimination on the basis of gender identity and denial of coverage for gender transition, pending the Supreme Court’s decision in G.G. v. Gloucester County School Board.[2]  The Supreme Court accepted certiorari in Gloucester in October 2016 to determine the… Continue Reading

HHS Proposes New Regulations Aimed At Stabilizing the Individual Market

Posted in Exchanges, Health Care Reform & ACA
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule  to stabilize the individual and small group markets to entice issuers to continue participation in the exchanges in 2018 despite continued uncertainty surrounding repeal and replacement proposals for the Affordable Care Act (ACA). The proposed rule, published today, would make the following changes… Continue Reading

ACA Repeal and Replace Update: President Trump’s Executive Order Directs Executive Branch to Minimize the Economic Burden of the ACA

Posted in Exchanges, Health Care Reform & ACA, Medicaid, Tax
On January 20, 2017, hours after being sworn in as the 45th president of the United States, President Donald Trump issued Executive Order 13765 that aims to “minimize the unwarranted economic and regulatory burdens” of the Affordable Care Act (ACA) while its repeal is “pending.”  The one-page Executive Order declares that it is the policy… Continue Reading

CMS Publishes Interim Final Rule to Address Third-Party Payment of Insurance Premiums by Medicare-certified Dialysis Providers

Posted in Exchanges, Fraud, Waste & Abuse, Health Care Reform & ACA, Medicaid, Medicare
On December 14, 2016, CMS issued an interim final rule with comment period to amend Medicare’s dialysis facility conditions for coverage to require certain disclosures to patients and health insurance issuers to address widespread concerns over inappropriate steerage of dialysis patients to individual market plans. After issuing an RFI about “inappropriate steering of people eligible… Continue Reading

Court Delays Action on Appeal of ACA Subsidies Case

Posted in Exchanges, Health Care Reform & ACA
On December 5, 2016, the U.S. Court of Appeals for the D.C. Circuit issued an order to stay  the administration’s appeal of the district court decision in U.S. House of Representatives v. Burwell, a case challenging Cost-Sharing Reduction (“CSR”) payments to health insurance issuers under the Affordable Care Act (“ACA”) Section 1402. The district court… Continue Reading

New California Law To Target Surprise Bills Impacts Payor Relationships With Non-Contracted Professionals

Posted in Exchanges, Litigation, Managed Care Lawsuit Watch
California recently enacted Assembly Bill 72 (“AB 72”) to target surprise medical bills from out-of-network professionals.  The new law applies to commercial plans licensed by the Department of Managed Health Care and the Department of Insurance.  AB 72 sets reimbursement rates for out-of-network professionals at in-network facilities at either the average contracted rate, or 125… Continue Reading

GAO Finds HHS Exceeded Authority in Implementation of Transitional Reinsurance Program

Posted in Exchanges, Health Care Reform & ACA, Uncategorized
The Government Accountability Office (GAO), in a letter to members of Congress, found that the implementation of the Transitional Reinsurance Program by the U.S. Department of Health and Human Services (HHS) violates the Affordable Care Act. The Transitional Reinsurance Program is one of three premium stabilization programs authorized by the Affordable Care Act (ACA), commonly… Continue Reading

CMS Renews Focus on Third-Party Payment of Insurance Premiums Steering Medicaid & Medicare Eligibles into Marketplace Plans

Posted in Exchanges, Fraud, Waste & Abuse, Health Care Reform & ACA, Medicaid, Medicare
On August 18, 2016, CMS issued a request for information on “inappropriate steering of people eligible for Medicare or Medicaid into Marketplace plans” by third parties. CMS voiced concern over “anecdotal reports” that Medicaid or Medicare eligibles received premium and cost-sharing assistance from third parties so they could enroll in Marketplace plans, enabling providers to… Continue Reading

Context Matters: Supreme Court Rules in Favor of ACA Subsidies

Posted in Exchanges, Health Care Reform & ACA
The “what will Congress do” news leads can now stop. The Supreme Court issued its decision in King v. Burwell and Congress does not need to fix anything because, by a vote of 6-3 in an opinion written by Chief Justice John Roberts, the Supreme Court held that the subsidy provisions of the ACA are… Continue Reading

OMB: Weak Oversight to Blame for Healthcare.gov Woes

Posted in Exchanges, Health Care Reform & ACA
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… Continue Reading

CMS Issues Final Rule on ACA Marketplace Enrollment

Posted in Exchanges, Health Care Reform & ACA
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… Continue Reading

State-Based Health Insurance Exchanges: What Does The Future Hold?

Posted in Exchanges
Last Thursday, state-based health insurance exchange executives gathered in Chicago to reflect on their experiences establishing their respective exchanges. While these executives were meeting, the full D.C. Circuit Court announced it would rehear the Halbig premium subsidy case and the Oregon exchange board met to discuss dismantling Cover Oregon and moving remaining functions to existing… Continue Reading

CCIIO Issues New Guidance on Grace Periods for Non-payment of Premiums in Exchanges

Posted in Exchanges, Health Care Reform & ACA
On July 16, 2014, the Consumer Information and Insurance Oversight (CCIIO) division of the Centers for Medicare & Medicaid Services (CMS) released an Enrollment Bulletin for the individual markets of Federally-facilitated Exchanges (FFEs) about grace periods for premium non-payment. The Bulletin addresses when grace periods related to terminations for premium non-payment fall across enrollment periods… Continue Reading

United States Appellate Courts Issue Dueling Opinions on Availability of Tax Credits in Federally Facilitated Exchanges

Posted in Exchanges, Health Care Reform & ACA, Litigation
The Obama Administration received mixed messages yesterday when two federal appellate courts issued contradictory rulings on whether tax credits are available for individuals to purchase health insurance from federally facilitated Exchanges operating in 36 states. The U.S. Court of Appeals for the D.C. Circuit delivered a stiff rebuke to the Obama Administration, issuing a 2-1… Continue Reading

Secretary Burwell Announces Changes Regarding Management and Accountability for the 2015 Open Enrollment Period

Posted in Exchanges, Health Care Reform & ACA
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… Continue Reading

COBRA, Cost-Sharing, and Other Matters Clarified in the Affordable Care Act’s Nineteenth Set of FAQs

Posted in ERISA, Exchanges, Health Care Reform & ACA
On May 2, 2014, the Internal Revenue Service, Department of Health and Human Services, and Department of Labor (the “Departments”) collectively released the Affordable Care Act’s (ACA) nineteenth set of Frequently Asked Questions (FAQs). The FAQ addressed outstanding questions regarding Health Care Continuation Coverage (COBRA) and Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA)… Continue Reading

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

Posted in Exchanges, Health Care Reform & ACA
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

Third Party Payment of Qualified Health Plan Premiums Interim Final Rule

Posted in Exchanges, Health Care Reform & ACA
The comment period closed today for an interim final rule that requires qualified health plans (QHPs) to accept premium and other cost sharing payments from certain federal and state programs and clarifies that failure to do so could result in a civil monetary penalty. The rule, promulgated on March 19th and effective on the same… Continue Reading

Obama Administration Changes Course on Sequester of Cost-sharing Subsidies for Low-Income Enrollees in Exchange Plans

Posted in Exchanges, Health Care Reform & ACA
The Obama Administration recently announced a policy change indicating that the Fiscal Year (FY) 2015 budget sequester will not cut cost-sharing subsidies for low-income enrollees in Affordable Care Act (ACA) health plans. According to a March 10, 2014 Office of Management and Budget (OMB) report detailing the federal government’s sequestration-based spending reductions for FY 2015,… Continue Reading

CMS Issues Final Notice Regarding Payment Parameters for 2015

Posted in Exchanges, Health Care Reform & ACA
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… Continue Reading

OMB Reviewing Regulations on Third-Party Payments to QHPs

Posted in Exchanges, Health Care Reform & ACA
An interim final rule addressing third-party premium payments to qualified health plans is under regulatory review at the Office of Management and Budget, according to an online posting on that agency’s website on March 4, 2014. Both providers and payors have anxiously watched for clarifications in this area following a series of conflicting statements from… Continue Reading

IRS Promulgates Clarifying Regulations Regarding Abstainer Penalties Under the ACA

Posted in Exchanges, Health Care Reform & ACA, Medicaid, Tax
On January 27, 2014, the Internal Revenue Service (IRS) issued proposed regulations (“Proposed Regulations”, available here) clarifying the penalties imposed on nonexempt persons who fail to maintain minimum essential coverage as required by Internal Revenue Code (Code) Section 5000A. Very generally, Code Section 5000A requires nonexempt persons to either (1) maintain minimum essential coverage, or (2)… Continue Reading

CMS Requests Comments on Exchange-Related Data Collection

Posted in Exchanges, Health Care Reform & ACA, HIPAA & Privacy
On February 10, 2014, the Centers for Medicare & Medicaid Services (CMS) published a notice seeking public comment on its revision to data elements being collected for coverage offered on and off the Exchange. In particular, CMS seeks comment on revisions to data collected by the Exchange to ensure that Qualified Health Plans meet certain… Continue Reading