Insurance Exchanges/Marketplaces

On November 14, 2013, the Centers for Medicare and Medicaid Services of the Department of Health and Human Services (CMS) issued a letter to state insurance commissioners detailing the Administration’s new “transitional policy” regarding non-grandfathered coverage in the small group and individual health insurance markets. Under the transitional policy, health insurance issuers may choose to

President Obama announced on November 14 that the Administration will allow health insurers to continue certain coverage in the individual and small group market which would have not otherwise met the market reform requirements of the Affordable Care Act (ACA). This change raises significant questions and operational problems for issuers, providers, employer sponsors of health plans, and other organizations operating in the health care industry. In conjunction with the President’s announcement, the Centers for Medicare & Medicaid Services of the Department of Health and Human Services (CMS) has issued a letter to state insurance commissioners (CMS Letter) detailing the Administration’s new “transitional policy” in regard to this issue. The CMS Letter provides some guidance regarding health insurance policies that now may be continued, and specifies the necessary conditions under which these policies may be continued. However, there remains much uncertainty as to whether issuers will be able to continue to offer these policies, as well as the overall impact on the insurance market.
Continue Reading The Obama Administration’s ‘Fix’ for Insurance Cancellations: Five Things Worth Taking into Account

On November 14, 2013, under increasing political pressure, President Obama announced that the Administration temporarily will allow insurers to renew some individual and small employer policies for 2014—even if these plans do not meet certain Affordable Care Act requirements, such as Essential Health Benefits. The new rules permit insurers, until October 1, 2014, to renew

In the wake of United States v. Windsor, the case in which the Supreme Court held the Defense of Marriage’s (DOMA) prohibition on federal recognition of same-sex marriages unconstitutional, the Internal Revenue Service issued Internal Revenue Ruling 2013-17. The Ruling held that same-sex individuals who were married under state law would be considered

On September 25, 2013, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule to establish the Basic Health Program pursuant to Section 1331 of the Affordable Care Act (ACA). The Basic Health Program aims at assisting individuals whose incomes exceed the threshold for Medicaid and similar programs, but who cannot afford to purchase coverage in the ACA’s Health Insurance Marketplaces (i.e., .individuals who have income levels between 133 to 200 percent of the federal poverty level). States that establish a Basic Health Program will receive federal funding equal to 95 percent of the amount of the premium tax credits and the cost sharing reductions that would have otherwise been provided to (or on behalf of) eligible individuals if these individuals enrolled in Qualified Health Plans through the Marketplaces.
Continue Reading CMS Publishes Proposed Rule on Basic Health Program

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 7, 2013, the Office of Personnel Management (OPM) released a proposed rule on federal employee health benefits for members of Congress and congressional staff. The Affordable Care Act (ACA) contains a provision requiring Congress and their staff to obtain health insurance coverage via an Affordable Insurance Exchange or a health plan created by

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