Individual/Small Group

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

On August 9, 2013, the Centers for Medicare and Medicaid Services (CMS) released guidance on State Alternative Applications for Health Coverage through the Small Business Health Options Program (SHOP). Beginning October 1, 2013, the new SHOP marketplaces will use applications to determining eligibility for participation in SHOP and enrollment in qualified health plans through the SHOP. In May 2013, CMS released model applications for shop coverage, but state-based SHOPs may also use an alternative SHOP application as approved by CMS. This guidance provides background on the development process, review, and approval of alternative SHOP applications.

States may submit SHOP applications for approval, and the alternative applications must meet the general principles of the model applications by adhering to regulations implementing the Affordable Care Act. Some aspects of the application will require formal approval. But there are also a number of ways a state can adopt the model applications without formal approval as an alternative application. For example, states can add state SHOP program names and contact information to the application, change the visuals of the application for proper branding, add language to the privacy statement, or remove questions about text messaging. Moreover, no approval is required for some modifications that minimize consumer burden.


Continue Reading CMS Issues Guidance on Alternative SHOP Applications

On August 5, 2013, the Centers for Consumer Information & Insurance Oversight (CCIIO) issued a new Question and Answer (Q&A) on whether Marketplaces will verify consumer income as part of the eligibility process for advance payment of premium tax credits and cost-sharing reductions. The Q&A explained that Marketplaces will verify this information via documentation submitted

On July 11, 2013, the U.S. Court of Appeals for the Fourth Circuit, reconsidering a case in light of National Federal of Independent Business v. Sebelius, 132 S. Ct. 2566 (2012) (hereinafter NFIB), upheld the constitutionality of both the individual mandate and employer mandate of the Patient Protection and Affordable Care Act (ACA). In Liberty University v. Lew, the Court stated that the employer mandate was a valid exercise of Congress’s authority under the Commerce Clause and its taxing power. Liberty University v. Lew, No. 10-2347, 2013 WL 3470532, at *15 (4th Cir. July 11, 2013). The Court also rejected religion-based challenges to both the individual and employer mandates under the ACA. Id. at 16.

Liberty University, a large employer, filed suit against the Secretary of the United States Treasury, seeking a declaration that the individual and employer mandates are invalid. Specifically, Liberty University alleged that the mandates exceeded Congress’s Article I powers. The district court upheld the constitutionality of both mandates. On appeal, the Fourth Circuit held that the Anti-Injunction Act barred it from considering the claims and remanded the case back to the district court with instructions to dismiss for lack of jurisdiction. The Supreme Court granted the plaintiffs’ petition for certiorari, vacated the Fourth Circuit’s judgment, and remanded for further consideration in light of NFIB.


Continue Reading Fourth Circuit Upholds Constitutionality of Both Individual and Employer Mandate

On July 10, 2013, the Center for Medicare and Medicaid Services (CMS) released a “Frequently Asked Question” response regarding CCIIO assessment fees. The question asked “Can States collect assessment fees in their first year of Exchange operations for use in the second year of operations?” The response explained that States can decide to collect assessment

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