After much anticipation over the past few weeks, the Federal Register from Tuesday, June 9th contains the Final Rule proposing changes to the Medicare Shared Savings Program (MSSP) from the Centers for Medicare & Medicaid Services (CMS). The finalized changes to the MSSP provide additional flexibility and choice to Accountable Care Organizations (ACOs) currently participating in the program, but much uncertainty remains for future participants or those determining whether to continue their involvement in this initiative to control health care costs while improving quality for Medicare beneficiaries.

As expected, CMS established a “Track 3” model for MSSP ACOs with prospective beneficiary assignment that will not require ACOs that participated in the Track 1 one-sided risk model to transition to two-sided risk after the first three-year MSSP participation period. In contrast to the proposed rule, second-time Track 1 participants will have continued eligibility for 50 percent of the shared savings they earn during the subsequent MSSP agreement period. Other helpful changes that CMS finalized for ACOs participating in the MSSP include, but are not limited to:

  • clarifying key MSSP-related definitions in section 42 C.F.R. § 425.20;
  • revising the annual benchmark-setting methodology in 42 C.F.R. § 425.602 to equally weight each benchmark year and to account for shared savings in prior ACO agreement periods when resetting the historical benchmarks;
  • creating multiple Minimum Savings Rate (MSR)/Minimum Loss Rate (MLR) options for Track 2 (two-sided risk) ACOs beginning their MSSP agreement periods in January 2016; and
  • counting primary care services performed by Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists at the beginning of the beneficiary assignment process (without distinguishing whether such professionals are performing primary or specialty services).


Continue Reading Previewing the Final Rule Implementing Changes to Medicare Shared Savings Program

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

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 Treasury Department and the Internal Revenue Service released a final regulation providing guidance to Blue Cross and Blue Shield (and other qualifying healthcare organizations) on computing and applying the medical loss ratio (MLR) under Code Section 833(c)(5), which is effective as of January 7, 2013 and applies to tax years beginning after December 31, 2013. Under Code Section 833(c)(5), qualifying organizations (including Blue Cross and Blue Shield organizations) are provided with favorable income tax treatment, including: (1) treatment as stock insurance companies, (2) a special deduction under Code Section 833(b), and (3) the computation of unearned premium reserves based on 100 percent of unearned premiums under Code Section 832(b)(4). However, the Patient Protection and Affordable Care Act (ACA) added a provision to the Code, requiring that a qualifying organization must  have a medical loss ratio (MLR) of at least 85 percent to get favorable income tax treatment under Code Section 833(c)(5). For purposes of Code Section 833, an organization’s MLR is its percentage of total premium revenue expended on reimbursement for clinical services provided to enrollees under its policies during such taxable year (as reported under Section 2718 of the Public Health Service Act (PHSA)).
Continue Reading Treasury Dept. and IRS Release Guidance to Qualifying Healthcare Organizations Computing and Applying MLR

On July 5, 2013, the Department of Health and Human Services issued a final rule on various provisions of the Affordable Care Act, including essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeals processes, premiums and cost sharing, and eligibility verification by exchanges. In part, the final rule delays implementation of

The Centers for Medicare and Medicaid Services (CMS) issued a final rule on May 31, 2013, effective July 31, 2013, regarding the Small Business Health Options Program (SHOP) under the Affordable Care Act (ACA).

The ACA permits individuals and small businesses to purchase private health insurance through Health Insurance Marketplaces; section 1311(b)(1)(B) of the ACA

On May 20, 2013, the Centers for Medicare and Medicaid Services (CMS) released the final regulations on the Affordable Care Act’s (ACA) medical loss ratio (MLR) requirements for Medicare Advantage and Medicare Prescription Drug Benefit Programs (PDP). The final MLR rule is largely identical to the proposed rule and generally tracks the requirements of the