Health Reform Information

Health Reform Information

 

Patient Protection and Affordable Care Act Implementation Deadlines and Regulations/Guidance as of May 20, 2013

Key Provisions Implementation Summary Deadlines
Essential Health Benefits (EHB) Benchmark Plan in Individual and Small Group Markets States must select one plan from ten benchmark options in the existing insurance market to serve as the reference point for EHB services (benchmark options include 3 largest small employer plans by enrollment, 3 largest state employee plans, 3 largest federal employee plans, or the largest commercial, non-Medicaid HMO in the State).If a State failed to select a benchmark plan by September 30, 2012,  the EHB benchmark defaulted to the largest small-group plan in the State. September 30, 2012 (see HHS Final Rule on Standards Related to EHB, Actuarial Value, and Accreditation, CCIIO Bulletin on EHB Rulemaking Process, CCIIO Illustrative List of Three Largest Small Group Plans by State, FAQs on HHS Approach to Defining EHBs)NASADAD Comments on EHB Bulletin
Health Insurance Marketplaces The law calls for the creation of Health Insurance Marketplaces in each State to enable all Americans to purchase more affordable private insurance. Plans offered in the Marketplace must provide at least a basic level of essential health benefits and services. January 1, 2014 (see HHS Final Rule on the Establishment of Marketplaces and Qualified Health Plans; Exchange Standards for Employers)NASADAD Comments on the Development of State Exchanges
State Notification Regarding Health Insurance Marketplaces States must indicate to the Secretary of the Department of Health and Human Services (HHS) if they wish to operate a State-based Marketplace or a Partnership Marketplace and develop a Marketplace Blueprint. Submit by December 14, 2012 for State-Based Marketplace Letter of Intent and Blueprint; Submit by February 15th, 2013 for Partnership Marketplace Letter of Intent and Blueprint (see Letter from Secretary Sebelius Extending Marketplace Deadlines, HHS Blueprint, HHS Final Rule on the Establishment of Marketplaces and Qualified Health Plans; Exchange Standards for Employers)
Navigators and In-Person Assistance (IPA) Programs The law requires that all Federal and State-based exchanges have a navigator program. Navigators will assist consumers and small employers with the enrollment process in the exchanges through education efforts, assistance in applying for and enrolling in coverage through the exchanges, and providing referrals.  The law also proposes an optional In-Person Assistance (IPA) program that is intended to provide additional assistance options to states and to fill in the gaps in Navigator programs during the first open enrollment period. Navigators and IPA program providers are expected to be highly trained and in some states, certified. The role of Navigators and IPA programs differ across states, and some States require that each targets specific populations in order to reach a wider group of eligible consumers. Award Announcements- Applications Due by June 7th, 2013Awards were announced August 15, 2013 (See CMS List of Navigator Awardees and Information about In-Person Assistance in the Health Insurance Marketplace)To read the FOA, visit http://www.grants.gov/ and search for CFDA number 93.750(See HHS Proposed Rule on Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel)
Medicaid Expansion Americans who earn less than 133 percent of poverty (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid in States that chose to accept Federal funds to expand their Medicaid Program. States that opt-in to the expansion will receive 100 percent federal funding for the first three years to support this expanded coverage, phasing to 90 percent federal funding in subsequent years. States can also apply for waivers to expand their program before January 1, 2014. (the expansion is no longer mandatory due to the Supreme Court’s decision that a mandatory expansion of Medicaid is unconstitutional, see National Federation of Independent Business et al. v. Sebelius) January 1, 2014 (see CMS Final Rule on Medicaid Eligibility Under the Affordable Care Act)NASADAD Comments on Medicaid Expansion
Essential Health Benefits (EHB) in Medicaid Alternative Benefit Plans State Medicaid programs have the option of extending coverage through Social Security Act Section 1937 Medicaid benchmark or benchmark equivalent plans (known as Alternative Benefit Plans). In accordance with the ACA, any Alternative Benefit Plan must cover EHB. The four Alternative Benefit Plan options include the Standard Blue Cross Blue Shield Federal Employee Health Benefit Plan (FEHBP), State Employee Coverage plan, the commercial HMO with the largest insured commercial, non-Medicaid enrollment in the State, or a Secretary approved alternative (may include traditional Medicaid plan). January 1, 2014 (see CMS Final Rule on Essential Health Benefits in Medicaid Alternative Benefit Plans, CMS Proposed Rule on Essential Health Benefits in Medicaid Alternative Benefit Plans, CMS Letter to Medicaid State Directors on EHB and Alternative Benefit Plans)
Medicare Value-Based Purchasing Establishes a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and requires plans to be developed to implement value-based purchasing programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers. October 1, 2012 (see CMS Final Rule)
Medicaid Payments for Primary Care In 2013 and 2014, Medicaid payment rates for primary care doctors will be increased to equal Medicare reimbursement rates. States will receive 100 percent federal financing to pay for the increase. January 1, 2013-January 1, 2015 (see CMS News Release)
Electronic Health Records Health insurance plans must implement uniform standards for electronic exchange of health information. January 1, 2013
Public Reporting on Physician Performance Begins public reporting of physician performance information, based in part on patient feedback. January 1, 2013
Medicare Bundled Payment Pilot Program Establishes a national Medicare pilot program to develop and evaluate making bundled payments for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care. January 1, 2013 (see CMS Notice)
Individual Mandate Requires U.S. citizens and legal residents to have qualifying health coverage or face a tax, with certain exemptions (including religious and hardship exemptions). January 1, 2014
Health Insurance Premium and Cost-Sharing Subsidies Provides refundable tax credits and cost sharing subsidies to eligible individuals. Premium subsidies are available to families with incomes between 133-400 percent of the federal poverty level to purchase insurance through the Exchanges, while cost sharing subsidies are available to those with incomes up to 250 percent of the federal poverty level. January 1, 2014 (see IRS Final Rule on Health Insurance Premium Tax Credits)
Guaranteed Availability of Insurance Requires guarantee issue and renewability of health insurance regardless of health status and allows rating variation based only on age (limited to a 3 to 1 ratio), geographic area, family composition, and tobacco use (limited to 1.5. to 1 ratio) in the individual and the small group market and the Exchanges. January 1, 2014
No Annual Limits on Coverage Prohibits annual limits on the dollar value of coverage. January 1, 2014
Multi-State Health Plans Requires the Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entity and at least one plan must not provide coverage for abortions beyond those permitted by federal law. January 1, 2014
Basic Health Plan Permits States the option to create a Basic Health Plan for uninsured individuals with incomes between 133-200 percent of the federal poverty level who would otherwise be eligible to receive premium subsidies in the Exchange. January 1, 2014 (see CMS Request for Information Regarding State Flexibility to Establish BHP)
Health Care Choice Compacts States may form health care choice compacts that allow insurers to sell policies across state lines, in any State participating in the compact. January 1, 2016
CO-OP Health Insurance Plan Creates the Consumer Operated and Oriented Plan (CO-OP) to foster the creation of non-profit, member-run health insurance companies. July 1, 2013 (see HHS Final Rule, Grant Awardees)
Sources: The Henry J. Kaiser Family Foundation, Health Reform Source: Implementation Guideline, http://healthreform.kff.org/timeline.aspx
The White House, The Affordable Care Act- Implementation Timeline, http://www.whitehouse.gov/healthreform/timeline

Additional Health Reform Resources:

• State Refor(u)m: http://www.statereforum.org/
• Coalition for Whole Health: http://www.coalitionforwholehealth.org/
• Kaiser Family Foundation (KFF): http://healthreform.kff.org/
• National Association of Medicaid Directors (NAMD): http://medicaiddirectors.org
• National Association of Insurance Commissioners (NAIC): http://www.naic.org/
• National Conference of State Legislatures (NCSL): http://www.ncsl.org/issues-research/health.aspx?tabs=831,139,1156