Insurance Exchanges/Marketplaces

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

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) releases, out-of-pocket maximums and limitations on cost-sharing, coverage of preventive services, FSA carryover and excepted benefits, and summary of benefits (SBA) requirements.

COBRA and CHIPRA

Following the Department of Labor’s (DOL) release of proposed COBRA regulations to better align COBRA with the ACA, the Departments issued FAQ guidance discussing COBRA’s general and election notice requirements, specifically when the notice is to be provided and the content of the notice. Although the proposed regulations eliminate the current model notice, although the FAQs state that the old version can still be used as good faith compliance with the notice requirement. (FAQ 1). Once the updated model notice is finalized it will be available on the DOL website. Additionally, the Departments noted that qualified beneficiaries may want to compare the price of COBRA coverage with coverage under the Health Insurance Marketplace (the Marketplace). The FAQs state that “[q]ualified beneficiaries may be eligible for a premium tax credit (a tax credit to help pay for some or all of the cost of coverage in plans offered through the Marketplace) and cost-sharing reductions (amounts that lower out-of-pocket costs for deductibles, coinsurance, and copayments), and may find that Marketplace coverage is more affordable than COBRA.”

The Department also clarified the CHIPRA notice requirement for group health plans located in a State that provides premium assistance. Under CHIPRA each employee must be provided notice of the potential opportunities for premium assistance in the State that the employee resides.


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

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 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,

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

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 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) make a shared responsibility payment. The Proposed Regulations:

  1. explain which government-sponsored programs do not qualify as “government-sponsored minimum essential coverage”;
  2. clarify that “minimum essential coverage” excludes health plans and programs that consist solely of “excepted benefits”;
  3. clarify—for purposes of the “lack of affordable coverage” exemption—the required contribution for individuals eligible to enroll in an eligible employer-sponsored plan that provides employer contributions to health reimbursement arrangements (HRAs) or wellness program incentives;
  4. expand the definition of hardship exemptions that may be claimed on a federal income tax return and provide additional guidance; and
  5. clarify the computation of the monthly “shared responsibility payment” penalty amount.

Comments with respect to the Proposed Regulations are due by April 28, 2014, and a public hearing is scheduled for May 21, 2014.


Continue Reading IRS Promulgates Clarifying Regulations Regarding Abstainer Penalties Under the ACA

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

On November 25, 2013, the Department of Health and Human Services (HHS) released a Proposed Notice of Benefit and Payment Parameters for 2015 regarding the Affordable Care Act’s Transitional Reinsurance Program (TRP) fee.

The Proposed Notice includes the previously announced carve-outs from the TRP fee for the 2015 and 2016 years for certain self-insured, “self-administered”