Insurance Market Reform

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Final Rule: Eligibility for Exemptions and Minimum Essential Coverage Provisions

Jul 2013

The Department of Health and Human Services (HHS) issued the final regulation explaining the eligibility rules for receiving an exemption from the individual shared responsibility provision through a health exchange, as well as two subcategories of exemptions that will be available through the tax filing process. HHS’s final regulation includes rules that will ease implementation and help to ensure that the shared responsibility payment obligation applies only to the limited group of taxpayers who have ready access to affordable coverage but choose to spend a substantial period of time uninsured.


Impact of National Health Reform and State-Based Exchanges on the Level of Competition in the Nongroup Market

Jun 2013

One of the objectives of the Affordable Care Act (ACA) reform of the nongroup insurance market, including new market and rating rules and reliance on public health insurance exchanges, is to enhance competition. More competing health plans increases consumer choice, as well as the market pressure on health plans to manage administrative costs, improve their service and contract with clinical providers at optimal rates. Especially in the context of health plans contracting selectively with providers in order to hold down payment rates, a choice of more health plans serves consumers well and signals a vibrant market. This brief, prepared by Wakely Consulting Group, provides an early indicator of the level of competition among health insurers that market reforms and state-based exchanges are generating.


Incentives for Nondiscriminatory Wellness Programs in Group Health Plans - Final Rule

Jun 2013

The Department of Treasury, Department of Labor, and Department of Health and Human Services issued a joint final rule on employment-based, nondiscriminatory wellness programs. Specifically, these final regulations increase the maximum permissible reward under a health-contingent wellness program offered in connection with a group health plan from 20 percent to 30 percent of the cost of coverage. The final regulations further increase the maximum permissible reward to 50 percent for wellness programs designed to prevent or reduce tobacco use. These regulations also include other clarifications regarding the reasonable design of health-contingent wellness programs and the reasonable alternatives they must offer in order to avoid prohibited discrimination


Factors Affecting Self-Funding by Small Employers: Views from the Market

May 2013

Policy experts predict that small employers, especially those with younger and healthier employees, will increasingly establish “self-funded” health plans, leaving the traditional fully-insured market to obtain lower premiums and avoid market reforms under the Affordable Care Act. Through interviews with stakeholders in 10 study states, this paper describes factors that may influence whether and how extensively this change will occur. It also shows that states have minimal data on this potentially growing market, but they would be well served to improve their monitoring efforts so they can identify any increases in small group self-funding and resulting adverse selection, and respond appropriately.


Helping Consumers Understand the New Premium Tax Credit

May 2013

Beginning in 2014, the Affordable Care Act (ACA) introduces major reforms, including the start of a new advance payment Premium Tax Credit designed to lower the cost of coverage for qualified families purchasing in the new Health Insurance Marketplaces (exchanges).  While employer-provided coverage receives significant tax preferences, tax credits for individual or non-group health insurance have not been used in a broad way. What’s more, the advanceable and refundable nature of these new tax credits introduce new elements that most consumers have not previously encountered. Taken together, these facts raise the possibility that consumer confusion might be a barrier to using this new program to enroll in affordable coverage. 


FOA - Grants to States to Support Health Insurance Rate Review and Increase Transparency in Health Care Pricing

May 2013
CMS released a third cycle of Rate Review Grants - Grants to States to Support Health Insurance Rate Review and Increase Transparency in Health Care Pricing, Cycle III of the Rate Review Grant Program. This cycle of funding continues to support rate review efforts in states and bolsters state’s ability to establish or enhance data centers which collect, analyze, and publish reimbursement and health pricing data. 

Proposed Rule: State Disproportionate Share Hospital Allotment Reductions

May 2013

The Centers for Medicare and Medicaid Services (CMS) released a proposed rule on DSH payments. The proposed rule specifies the methodology for the annual reductions in DSH payments from fiscal year 2014 through fiscal year 2020, as required by the ACA. The rule also outlines some additional proposed DSH reporting requirements. A fact sheet is also available.


Notice of Proposed Rulemaking - Computation of, and Rules Relating to, Medical Loss Ratio

May 2013

The IRS released proposed regulations that provide guidance to Blue Cross and Blue Shield organizations, and certain other health care organizations, on computing and applying the medical loss ratio as detailed in the Affordable Care Act (ACA). That provision requires carriers to apply at least 80 percent of paid premiums to health care services and up to 20 percent to administrative costs. 


Proposed Rule: Minimum Value of Eligible Employer-Sponsored Plans

May 2013

This proposed rule released by the IRS provides further detail on the minimum value that employer-sponsored coverage must provide in order to comply with the ACA and not be subject to the employer mandate penalty. It also provides additional guidance on premium tax credits.


ACA Checklists for Departments of Insurance

May 2013

Stemming from training at insurance departments in various State Network states, Georgetown University Health Policy Institute (Georgetown) has released updated form review checklists. These resources are designed to help insurance regulators effectively implement Affordable Care Act (ACA) provisions, regulations, and other guidance by ensuring that insurance forms submitted by carriers meet all the ACA requirements.  They are in writable Microsoft Word document form, allowing insurance regulators to simply download and modify to their state’s specifications.

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