Tag Archives: Marketplace

CMS Issues Final Rule to Stabilize ACA Insurance Markets, While Emphasizing Marketplace Woes

The Centers for Medicare & Medicaid Services has published a final rule intended to help improve the risk pool and stabilize the Affordable Care Act (ACA) Insurance Exchanges for 2018 – even as CMS contends that consumers “have faced double-digit premium increases, fewer plans to choose from, and a market that continues to be threatened … Continue Reading

CMS Flags Potential Provider “Steering” of Medicare/Medicaid Beneficiaries to Favorable ACA Marketplace Plans to Obtain Higher Rates

CMS is putting health care providers on notice that it considers it “inappropriate” for providers to offer premium or cost-sharing assistance to Medicare or Medicaid beneficiaries in order to “steer” the patient to an individual market plan “for a provider’s financial gain.”  In a request for information to be published on August 23, 2016, CMS … Continue Reading

CMS Releases Draft 2017 Letter to QHP Issuers in Federally-facilitated Marketplaces

On December 23, 2015, CMS released its Draft 2017 Letter to Issuers in the Federally-facilitated Marketplaces, which provides operational and technical guidance to issuers seeking to offer qualified health plans (QHPs) in the Federally-facilitated Marketplaces or the Federally-facilitated Small Business Health Options Programs.  Comments will be accepted until January 17, 2016.… Continue Reading

OIG Early Alert on State-Based ACA Marketplace Funding Use

The OIG has issued an “Early Alert” warning regarding the use of federal funding by state-based marketplaces under the Affordable Care Act (ACA). The OIG notes that the ACA clearly prohibits marketplaces from using grant funds to support ongoing operations after January 1, 2015. The OIG expresses its “concerns that, without more detailed guidance from … Continue Reading

Obama Administration Finalizes Health Insurance Wraparound Coverage Rule

The Departments of Labor, Health and Human Services, and Treasury published a final rule on March 18, 2015 that amends the definition of excepted benefits to allow group health plan sponsors, in limited circumstances, to offer wraparound coverage to individuals who are purchasing individual health insurance in the private market, including through the Affordable Care … Continue Reading

CMS Finalizes 2016 ACA Marketplace Plan Benefit & Payment Parameters

The Centers for Medicare & Medicaid Services (CMS) has finalized its Affordable Care Act (ACA) Marketplace health plan payment parameters and essential benefit standards for 2016. The rule addresses numerous policies, including: allocation of risk corridors collections for 2016; recalibration of risk adjustment factors; revisions to reinsurance and cost sharing parameters; user fees for federally-facilitated … Continue Reading

OIG Announces Plans for Health Reform Oversight Activities

On February 24, 2015, the HHS Office of Inspector General (OIG) released its “Health Reform Oversight Plan” for FY 2015, which describes the OIG’s current and planned efforts to oversee the implementation and management of HHS programs under the ACA. The plan outlines the OIG’s key tactical considerations (e.g., assessing relative risks; monitoring emerging issues … Continue Reading

Administration Issues Proposed Rules on ACA Summary of Benefits and Coverage, Excepted Benefits/Wraparound Coverage

On December 30, 2014, the Internal Revenue Service (IRS), the Employee Benefits Security Administration (EBSA), and the Centers for Medicare & Medicaid Services (CMS) published a proposed rule that would revise Affordable Care Act (ACA) summary of benefits and coverage (SBC) and uniform glossary requirements for group health plans and health insurance coverage. The changes, which … Continue Reading

CMS Proposes 2016 ACA Marketplace Plan Benefit & Payment Parameters

CMS has issued a proposed rule that would establish ACA Marketplace health plan payment parameters and essential benefit standards for 2016. Specifically, the wide-ranging proposed rule addresses, among other things: the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters; user fees for federally-facilitated exchanges; standards for qualified health plans, including network adequacy and … Continue Reading

Upcoming House Hearings to Address ACA Implementation, Accelerating Medical Innovation

On September 9, 2014, the House Energy and Commerce Subcommittee on Health is holding a hearing entitled “21st Century Cures: Examining the Regulation of Laboratory Developed Tests.” The hearing will focus on the FDA’s recent guidance on the regulation of lab developed tests and its “impact on innovation and the practice of precision medicine.” The panel … Continue Reading

CMS Finalizes ACA Marketplace Eligibility Redetermination/Renewal Process for 2015

On September 5, 2014, CMS is publishing a final rule that specifies additional options for annual eligibility redeterminations and renewal and re-enrollment notice requirements for qualified health plans (QHP) offered through the ACA insurance Exchange/Marketplace, beginning with annual redeterminations for coverage for plan year 2015. The rule provides an auto-enrollment process intended to provide current … Continue Reading

OIG, GAO Reports Focus on Healthcare.gov Operations

The OIG has issued two reports on implementation of the ACA health insurance “Marketplaces.” The first report, “Marketplaces Faced Early Challenges Resolving Inconsistencies with Applicant Data,” looked at the extent to which the federal and state health insurance marketplaces ensured the accuracy of information submitted by insurance applicants, including information related to eligibility for premium … Continue Reading

Proposed ACA Eligibility Redetermination/Renewal Process for 2015

HHS has issued a proposed rule that would specify additional options for annual eligibility redeterminations and renewal and re-enrollment notice requirements for qualified health plans offered through the ACA insurance Exchange/Marketplace, beginning with annual redeterminations for coverage for plan year 2015.  Comments are due July 28, 2014.… Continue Reading

OIG Releases Spring Semiannual Report Highlighting Major Program Integrity Efforts

The OIG has issued its spring Semiannual Report to Congress, which summarizes major OIG activities during the period of October 2013 through March 2014. The OIG highlights “ramped up” oversight of Affordable Care Act implementation efforts, particularly with regard to eligibility systems, payment accuracy, contractor oversight, and data security associated with the Health Insurance Marketplaces. … Continue Reading

CMS to Allow Retroactive ACA Insurance Subsidies for Certain Non-Marketplace Plans

CMS has announced that in light of persistent problems individuals have had enrolling in qualified health plans (QHPs) through some state-run Marketplaces, it will now allow individuals to access premium tax credits and cost-sharing reductions on a retroactive basis in certain circumstances. Specifically, in guidance dated February 27, 2014, CMS states that if a Marketplace … Continue Reading

Obama Administration Aligns Health Exchange Enrollment Deadline and “Shared Responsibility” Penalty Trigger

CMS recently issued guidance to ensure that individuals who purchase insurance through the ACA Marketplace/Insurance Exchange near the end of the initial open enrollment period are not subject to a penalty for a break in insurance coverage. By way of background, beginning in 2014, the ACA requires every individual to maintain health coverage (known as … Continue Reading

Congressional Hearings Focus on Rocky HealthCare.gov Rollout

Several House committees have held hearings to grill HHS officials and their contractors on various problems consumers and insurers have encountered during the first month of the HealthCare.gov insurance portal’s operation. On October 24, the House Energy and Commerce Committee held a hearing entitled on "PPACA (Patient Protection and Affordable Care Act) Implementation Failures: Didn’t … Continue Reading

CMS Finalizes ACA Exchange Program Integrity & Financial Oversight Standards

On October 30, 2013, CMS published a final rule that sets forth financial integrity and oversight standards for participants in Affordable Care Act (ACA) Insurance Exchanges/Marketplaces. According to a CMS press release, these policies largely are unchanged from previous proposed rules and guidance documents. Among other things, the rule addresses: oversight of state-operated risk adjustment … Continue Reading

ACA Health Insurance Marketplace Opens for Business to Mixed Reviews

On October 1, 2013, the Affordable Care Act’s (ACA) long-awaited Health Insurance Marketplace was launched at www.healthcare.gov. As has been widely reported, many consumers experienced technical problems using the federal site to enroll in qualified health plans, which the Administration has largely chalked up to greater-than-expected demand and site capacity issues that are being addressed … Continue Reading
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