Tag Archives: Qualified Health Plans (QHPs)

CMS Adopts 2019 ACA Health Plan Policies

CMS has released its final rule updating policies applying to qualified health plans (QHPs) offered on Affordable Care Act (ACA) Exchanges for 2019.  In the final rule, CMS stresses its goal of providing states greater flexibility and control over their insurance markets, particularly in the areas of: selection of essential health benefits benchmark plans; the … Continue Reading

CMS Seeks Input on “Evolution” of State Innovation Models Initiative, Including Potential Inclusion in MACRA Advanced Alternative Payment Models (APMs)

CMS is soliciting public input on the “evolution” of its State Innovation Models (SIM) Initiative, which was launched in 2013 to accelerate state design and testing of multi-payer payment and delivery models to generate savings and improve care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. In a September 8, 2016 press release, … Continue Reading

CMS Proposes ACA Marketplace Benefit and Payment Parameters for 2018

CMS has proposed its annual Notice of Benefit and Payment Parameters, which would apply to participation in Affordable Care Act (ACA) Health Insurance Marketplaces for 2018. In particular, the rule proposes revisions to the risk adjustment methodology to address, among other things:   risk associated with enrollees who are not enrolled for a full 12 months; … 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 Finalizes 2017 Requirements for ACA Marketplace Plans

CMS has published its annual Notice of Benefit and Payment Parameters, which governs participation in the Affordable Care Act (ACA) Health Insurance Marketplaces for 2017.  The sweeping rule addresses protection of consumers enrolled in Marketplace plans, network adequacy, marketplace premium stabilization programs, and various other refinements to Marketplace requirements.  Major provisions of the rule include … 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

Obama Administration Proposes 2017 ACA Marketplace Plan Benefit and Payment Parameters

On December 2, 2015, CMS is publishing its annual proposed Notice of Benefit and Payment Parameters, which would govern participation in the Affordable Care Act (ACA) Health Insurance Marketplaces for 2017. The wide-ranging rule includes a number of provisions intended to protect consumers enrolled in Marketplace plans, enhance transparency, improve marketplace premium stabilization programs, and … Continue Reading

OIG Report Assesses Accuracy of CMS Financial Assistance Payments to ACA QHP Issuers

According to a recent OIG report, CMS’s internal controls did not effectively ensure the accuracy of almost $2.8 billion in advance cost-sharing reduction (CSR) payments made to ACA qualified health plan (QHP) issuers during the period of January through April 2014. As a result, the OIG recommended that CMS take a series of steps to … 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

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

HHS Revises ACA Contraception Coverage Requirements

The Obama Administration has issued two regulations addressing coverage of contraceptive services under QHPs in response to recent court rulings (in particular the Supreme Court ruling in Burwell v. Hobby Lobby Stores, Inc.) addressing certain religious objections to such coverage. First, an interim final rule provides an additional pathway for nonprofit organizations eligible for a … 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

CMS Finalizes ACA Exchange, Insurance Market Standards for 2015 and Beyond

On May 27, 2014, CMS published a final rule updating ACA Affordable Insurance Exchange and insurance market standards beginning in 2015. Among other things, the rule addresses standards related to: standardized consumer notices regarding insurance product discontinuation and renewal; Qualified Health Plan (QHP) quality data reporting to support quality ratings for plans on the insurance … Continue Reading

Obama Administration Continues to Update ACA Insurance Exchange and Health Plan Regulations

The Administration has issued numerous regulations recently that make additional changes to operational policies, payment provisions, and other standards applicable to health plans and Health Insurance Exchanges (also called Marketplaces) under the Affordable Care Act (ACA). Highlights include the following:… Continue Reading

CMS Releases Subregulatory Guidance on ACA Insurance Coverage, Exchange Issues

Recent CMS subregulatory guidance and related announcements regarding ACA insurance coverage and insurance exchange issues include the following: On March 14, 2014, CMS released its final “2015 Letter to Issuers in the Federally-facilitated Marketplaces,” which provides operational and technical guidance to issuers seeking to offer qualified health plans (QHPs) in a federally-facilitated Marketplace and/or SHOP. CMS is … Continue Reading

CMS Rule Requires Qualified Health Plans to Accept Certain Third-Party Premium Payments

Today CMS published an interim final rule with comment period that requires qualified health plan (QHP) issuers to accept premium and cost-sharing payments made on behalf of enrollees by the Ryan White HIV/AIDS Program, Indian tribes and organizations, and other federal and state government programs that provide premium and cost sharing support. This rulemaking was prompted by … 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

CMS Issues Draft Guidance for Qualified Health Plan Issuers for 2015

On February 4, 2014, CMS released draft operational and technical guidance to health insurance issuers that seek to offer Qualified Health Plans (QHPs) in a Federally-Facilitated Marketplace (FFM) and/or a Federally-Facilitated Small Business Health Options Program (FF-SHOP) in 2015 and beyond (unless superseded in future years by subsequent regulations or guidance). Among many other things, the … Continue Reading

CMS Seeks Input on Quality Ratings for ACA Exchange Plans

On November 19, 2013, CMS published a notice seeking comments on its proposed Quality Rating System (QRS) framework for rating Qualified Health Plans (QHPs) offered through an ACA Affordable Insurance Exchange. Specifically, CMS lists proposed QRS quality measures that QHP issuers would be required to collect and report, and describes the hierarchical structure of the … Continue Reading

CMS Finalizes ACA Health Insurance Exchange “Navigator” Standards

On July 17, 2013, CMS published a final rule to establish standards for “Navigators” in federally-facilitated and state partnership Affordable Insurance Exchanges under the ACA. Under prior CMS regulations, Exchanges must award grants to Navigators to provide impartial information to consumers about health insurance, the Exchange, Qualified Health Plans (QHPs), various insurance affordability programs, and … Continue Reading

CMS Proposes ACA Exchange/Qualified Health Plan Financial Integrity and Oversight Standards

On June 19, 2013, CMS published a proposed rule that sets forth financial integrity and oversight standards for participants in ACA Affordable Insurance Exchanges/Marketplaces.  Among other things, the rule addresses: oversight of premium stabilization programs; oversight provisions related to state Exchanges, such as those pertaining to financial integrity and maintenance of records; standards for states’ … Continue Reading

CMS Publishes Final ACA Small Business Health Option Program (SHOP) Rule

On June 4, 2013, CMS published a final rule that builds on and revises previously-adopted regulations on the administration of the ACA’s Small Business Health Options Program (SHOP), which will help small employers offer employees a variety of qualified health plans (QHPs). Specifically, the rule adds changes in eligibility for state premium assistance under Medicaid … Continue Reading

CMS Letter to Issuers on Federally-Facilitated and State Partnership Exchanges

CMS has released a letter providing operational and technical guidance for issuers seeking to offer Qualified Health Plans (QHPs) on Federally-facilitated and State Partnership Exchanges. The letter addresses, among other things, the QHP certification process; QHP performance and oversight; enrollment and premium payment; and consumer support. There is also an appendix with additional guidance on … Continue Reading
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