Implementation, Regulations, and Guidance

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Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, and Eligibility Appeals

This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act). Specifically, this final rule outlines Exchange standards with respect to eligibility appeals, agents and brokers, privacy and security, issuer direct enrollment, and the handling of consumer cases.



Privacy Act of 1974; CMS Computer Match No. 2013-10; HHS Computer Match No. 1310

In accordance with the requirements of the Privacy Act of 1974, as amended, this notice announces the establishment of a CMP that CMS plans to conduct with the Department of Homeland Security (DHS), United States Citizenship and Immigration Services (USCIS).



HHS Releases New Information To Show How the Affordable Care Act Benefits Americans

On July 29th, 2013, the Department of Health and Human Services (HHS) released new information showing how the Affordable Care Act benefits the Americans. According to HHS, over 6.6 million people with Medicare have saved over $7 billion on prescription drugs as a result of the Affordable Care Act. These savings average $1,061 per beneficiary in drug costs while a beneficiary is in the "donut hole" (a coverage gap currently built into Medicare Part D) that the law closes over time. HHS also announced that 16.5 million people with traditional Medicare took advantage of at least one free preventive service in the first six months of 2013.



Proposed Marketplace Integrity Guidelines Outlined

CMS has released a proposed rule outlining program integrity guidelines for the Health Insurance Marketplace (Marketplace) and premium stabilization programs. Through the Affordable Care Act, consumers and small businesses will have access to new Marketplaces where they can access quality, affordable private health insurance. Consumers in every state will be able to buy insurance from qualified health plans directly through these Marketplaces and may be eligible for tax credits to lower the cost of their health insurance. Many of the provisions in the proposed rule build on guidance previously issued to states and other key stakeholders. These policies offer clarity on the oversight of various premium stabilization and affordability programs, build on state options regarding the Small Business Health Options Program, and provide technical clarifications. is the official national website of the Health Insurance Marketplaces. Open enrollment in the Marketplace begins October 1, 2013, with coverage to begin January 1, 2014.

pdf File 2013-14540.pdf [download]


Three State Paths to Improve Medicaid Managed Long-Term Care: Florida, New Jersey, and Virginia

Emerging MLTSS programs are shaped not only by a state's internal resources, but also by the state's experiences in interacting with long-term service and support providers, managed care plans, and beneficiaries. This brief looks at the MLTSS program design and implementation decisions made by three states to inform other states' planning. It also identifies how states' efforts in MLTSS pave the way for future coordination of Medicare and Medicaid benefits.

pdf File Three Paths to Medicaid MLTSS FINAL 2 .pdf [download]


GAO Testimony on the Status of CMS Efforts to Establish Exchanges

John E. Dicken of the Government Accountability office delivered this testimony on the status of CMS efforts to establish federally facilitated health insurance exchanges and the federal data services hub.

pdf File 655905.pdf [download]


CMS final rule on Standards for Navigators and Non-Navigator Assistance Personnel; Consumer Assistance Programs, and Certified Application Counselors

This final rule addresses various requirements applicable to Navigators and non-Navigator assistance personnel in Federally-facilitated Exchanges, including State Partnership Exchanges, and to non-Navigator assistance personnel in State Exchanges that are funded through federal Exchange Establishment grants. It finalizes the requirement that Exchanges must have a certified application counselor program. It creates conflict-of-interest, training and certification, and meaningful access standards; clarifies that any licensing, certification, or other standards prescribed by a state or Exchange must not prevent application of the provisions of title I of the Affordable Care Act; adds entities with relationships to issuers of stop loss insurance to the list of entities that are ineligible to become Navigators; and clarifies that the same ineligibility criteria that apply to Navigators apply to certain non-Navigator assistance personnel.



CMS Releases Final Rule on Essential Health Benefits in Medicaid Alternative Benefit Plans, Eligibility Notices, Hearings, and Cost-Sharing

On July 5, 2013, CMS issued a final rule implementing provisions of the Affordable Care Act related to eligibility, enrollment, and benefits in Medicaid, the Children's Health Insurance Program (CHIP) and the Health Insurance Marketplace. This final rule addresses aspects of the Medicaid, CHIP and Marketplace eligibility notices and appeals processes; provides additional flexibility regarding benefits and cost sharing for state Medicaid programs; codifies several eligibility and enrollment provisions included in the Affordable Care Act and the Children's Health Insurance Program Reauthorization Act (CHIPRA) and provides operational guidance to help states implement their Health Insurance Marketplaces.



Rural Implications of the Primary Care Incentive Payment Program

Key Findings: - Both the number and proportion of providers eligible to receive Primary Care Incentive Payments in 2011, 2012, and 2013 increased during the years used to determine eligibility (2009, 2010, and 2011). - For most practice types, rural providers were more likely to be eligible for Primary Care Incentive Payments. However, rates of eligibility varied between provider types. - Rural Family Practice physicians were less likely to be eligible for Primary Care Incentive Payments than their urban counterparts.



Proposed Rules for Public Comment Regarding Medicaid Managed Care Regulations

The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (PRA), federal agencies are required to publish a notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, and to allow a second opportunity for public comment on the notice.



Health centers to help uninsured Americans gain affordable health coverage

Health and Human Services (HHS) Secretary Kathleen Sebelius today announced $150 million in grant awards to 1,159 health centers across the nation to enroll uninsured Americans in new health coverage options made available by the Affordable Care Act.



HHS Issues Final Rule on Individual Shared Responsibility Exceptions

On June 26, the Department of Health and Human Services (HHS) issued a final rule outlining the exemptions available for individuals from the "shared responsibility" payment under the Affordable Care Act (ACA). Notably, the rule allows people to claim a hardship exemption if they are ineligible for Medicaid solely as a result of a state choosing not to expand Medicaid as provided for in the ACA. According to prior guidance, people eligible for employer-sponsored plans whose plans do not follow a January to December calendar year will not be liable for an individual mandate penalty until the end of their 2013-2014 plan year.

pdf File 2013-15530 PI.pdf [download]


CMS Releases Final Rule on Exemptions from Shared Responsibility and other Minimum Essential Coverage Provisions

This final rule implements certain functions of the Affordable Insurance Exchanges ("Exchanges"). These specific statutory functions include determining eligibility for and granting certificates of exemption from the individual shared responsibility payment described in section 5000A of the Internal Revenue Code. Additionally, this final rule implements the responsibilities of the Secretary of Health and Human Services, in coordination with the Secretary of the Treasury, to designate other health benefits coverage as minimum essential coverage by providing that certain coverage be designated as minimum essential coverage. It also outlines substantive and procedural requirements that other types of individual coverage must fulfill in order to be certified as minimum essential coverage.



Final Rule: Coverage of Certain Preventive Services Under the Affordable Care Act

This document contains final regulations regarding coverage of certain preventive services under section 2713 of the Public Health Service Act (PHS Act), added by the Patient Protection and Affordable Care Act, as amended, and incorporated into the Employee Retirement Income Security Act of 1974 and the Internal Revenue Code. Section 2713 of the PHS Act requires coverage without cost sharing of certain preventive health services by non-grandfathered group health plans and health insurance coverage. Among these services are women's preventive health services, as specified in guidelines supported by the Health Resources and Services Administration (HRSA).



Guidance on State Alternative Applications for Health Coverage

Today, the Centers for Medicare & Medicaid Services (CMS) is releasing guidance on state alternative applications for health coverage. Most states will use the CMS-developed single streamlined application for health insurance coverage, unless they develop their own applications in accordance with this guidance.

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