Resources from the Federal Government

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Guidance for Issuers on Special Enrollment Periods for Complex Cases in the FFM after the Initial Open Enrollment Period

Apr 2014

This guidance details the special enrollment periods for consumers to enroll in Marketplace coverage after open enrollment closes on March 31. These special enrollment periods include special enrollment periods the Federally-Facilitated Marketplace (FFM) is currently processing that allow a consumer to select a plan outside of the open enrollment period, including life changes, benefit display errors, misrepresentation and some exceptional circumstances.


Proposed Rule: Exchange and Insurance Market Standards for 2015 and Beyond

Mar 2014

This proposed rule would address various requirements applicable to health insurance issuers, Health Insurance Marketplaces, Navigators, non-Navigator assistance personnel, and other entities under the ACA. Specifically, the rule proposes standards related to product discontinuation and renewal, quality reporting, non-discrimination standards, minimum certification standards and responsibilities of qualified health plan (QHP) issuers, the Small Business Health Options Program, and enforcement remedies in Federally-facilitated Marketplaces.


Final Rule: HHS Notice of Benefit and Payment Parameters for 2015

Mar 2014

This final rule sets forth payment parameters and oversight provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also provides additional standards with respect to composite premiums, privacy and security of personally identifiable information, the annual open enrollment period for 2015, the actuarial value calculator, the annual limitation in cost sharing for stand-alone dental plans, the meaningful difference standard for qualified health plans offered through a Federally-facilitated Exchange, patient safety standards for issuers of qualified health plans, and the Small Business Health Options Program.


Final Rule: State Administration of Basic Health Programs

Mar 2014

This final rule establishes the Basic Health Program (BHP), which provides states the flexibility to establish a health benefits coverage program for low-income individuals who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace. The BHP complements and coordinates with enrollment in a QHP through the Exchange, as well as with enrollment in Medicaid and the Children’s Health Insurance Program (CHIP). This final rule also sets forth a framework for BHP eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, and federal oversight.


Medicaid and CHIP: January 2014 Monthly Applications and Eligibility Determinations Report

Mar 2014

This report is the fourth in a series of monthly reports on state Medicaid and Children’s Health Insurance Program (CHIP) data, and represents state Medicaid and CHIP agencies’ eligibility activity for the calendar month of January 2014, which coincides with the fourth month of the initial open enrollment period for the Health Insurance Marketplace. This report includes state data and analysis regarding applications to Medicaid and CHIP agencies and the State Based Marketplaces (SBMs) and eligibility determinations made by the Medicaid and CHIP agencies.


Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the PTC and CSRs in 2014 Due to Exceptional Circumst

Mar 2014

Due to technical issues in establishing automated eligibility and enrollment functionality, Marketplaces have had difficulty in providing timely eligibility determinations to applicants and enrolling qualified individuals in Qualified Health Plans (QHPs) during the open enrollment period for the 2014 coverage year. Such a circumstance may be considered an exceptional circumstance for individuals who were unable to enroll in a QHP through the Marketplace due to these issues. This bulletin provides guidance on the availability of advance payments of the premium tax credit and cost-sharing reductions on a retroactive basis to an issuer, and clarifies the attendant responsibilities of the QHP issuer in this circumstance.


Health Insurance Marketplace: February Enrollment Report

Feb 2014

This is the fourth in a series of issue briefs highlighting national and state-level enrollment-related information for the Health Insurance Marketplace. This brief includes data for states that are implementing their own Marketplaces, and states with Marketplaces that are supported by or fully run by the Department of Health and Human Services. This brief also includes updated data on the characteristics of persons who have selected a Marketplace plan (by gender, age, and financial assistance status), and of the plans that they have selected (by metal level); along with additional data on the characteristics of people who have selected plans in the FFM and the plans they have selected.


Letter on Application of Liens, Adjustments and Recoveries, Transfer of Asset Rules and Post-Eligibility Income Rules to MAGI In

Feb 2014

This letter provides guidance to states on how the long-term services and supports-related rules apply to individuals who are eligible for Medicaid under Modified Adjusted Gross Income (MAGI) eligibility rules, and receive coverage for long-term services and supports (LTSS). Some people who need LTSS may qualify for Medicaid under MAGI rules. This guidance is intended to address states’ questions regarding whether the various Medicaid LTSS rules, including the estate recovery rules, will apply to MAGI individuals who are eligible for LTSS coverage.


Shared Responsibility for Employers Regarding Health Coverage

Feb 2014

This document contains final regulations providing guidance to employers that are subject to the shared responsibility provisions regarding employee health coverage enacted by the Affordable Care Act. These regulations affect large employers, those with 50 or more full-time employees, including full-time equivalent employees, during the prior year. Generally, an applicable large employer that, for a calendar month, fails to offer health coverage that is affordable and provides minimum value to its full-time employees may be subject to an assessable payment if a full-time employee enrolls for that month in a qualified health plan for which the employee receives a premium tax credit. These employers will need to begin complying with these regulations in 2015.


Implementation of Hospital Presumptive Eligibility

Feb 2014

Beginning in January 2014 all states must implement hospital PE and ensure that hospitals that participate in the Medicaid program can begin making PE determinations to provide temporary Medicaid coverage to individuals who qualify including children, pregnant women, parents, individuals formerly in foster care, and, if applicable in a state, adults covered under the new low-income adult eligibility group. CMS released this set of frequently asked questions for states and stakeholders regarding hospital PA. It discusses questions on the application process, the eligible populations, information on the qualified entities that can make hospital PE determinations, qualification standards for participating hospitals, and the federal matching funds available.

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