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May 2014 St@teside

Federal News and Guidance

Final Exchange Rule

On May 16, the U.S. Department of Health and Human Services (HHS) released the final rule for Exchange and Insurance Market Standards for 2015 and beyond. This rule addresses a wide-range of issues including the following:

  • Navigators, assisters, and certified application counselors: The rule clarifies when state regulations for consumer assistance entities are pre-empted by federal law, and it tacks on additional restrictions to the existing requirements for consumer assistance entities.
  • Expedited appeals for drug coverage: The rule provides guidance on the circumstances under which there must be an expedited exceptions process for drugs not covered by a plan’s formulary.
  • Risk corridors and medical loss ratio (MLR): The rule finalizes the provision that will raise the cap on administrative costs and profits in the risk corridors formula by 2 percent. It also incorporates a few changes to MLR in light of the delayed implementation of ICD-10 requirements.
  • Employee choice in SHOP: If a state insurance commissioner has concerns about employee choice destabilizing the state’s small group insurance market, he or she may submit a recommendation to HHS to delay employee choice in that state until 2016.
  • Quality reporting: Health insurance marketplaces now have until 2016 to begin implementing a five-star rating system for QHPs that is publically available, in addition to sharing the results of enrollee satisfaction surveys.

Additional information on the final rule can be found in this fact sheet, as well as this Health Affairs blog post.

Partnerships to Increase Coverage in Communities Initiative FOA
The U.S. Department of Health and Human Services (HHS) Office of Minority Health recently released this funding opportunity announcement to support outreach and enrollment under the ACA. The Partnerships to Increase Coverage in Communities Initiative will identify and assist minority populations, educate them about the Health Insurance Marketplace, and assist them with enrollment, completion of the application to determine eligibility, and purchase health insurance offered through the Marketplace. The deadline for applications is June 16.

Health Care Innovation Awards Round Two and State Innovation Model FOA
HHS announced twelve prospective recipients of the second round of Health Care Innovation Awards. Made possible by the ACA, these awards will support programs that focus on four priority areas of delivery system reform: rapidly reducing costs for patients with Medicare and Medicaid; improving care for populations with specialized needs; testing improved financial and clinical models for specific types of providers, including specialists; and linking clinical care delivery to preventive and population health.  Additional prospective recipients will be announced in the coming months.

Also, HHS announced up to $730 million in available funding as part of the State Innovation Models Initiative to help states design and test improvements to their public and private health care payment and delivery systems. Projects should aim to improve health, improve care, and decrease costs for consumers, including Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. As part of the State Innovation Models initiative, states, territories and the District of Columbia can apply for either a Model Test award to assist in implementation or a Model Design award to develop or enhance a comprehensive State Health Care Innovation Plan. Up to 12 states will be chosen for Model Testing awards ($700 million available) and up to 15 states will be chosen for Model Design work ($30 million available). Letters of intent are due by June 6.