Tag Archives: ppaca

Amendment to the Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan Under the PPACA

This regulation, issued on November 15, 2010, amends an earlier regulation published in June that outlined rules governing whether group health plans and health insurance coverage in both the individual and group markets can maintain “grandfathered” health plan status. The grandfathered status allows plans to retain an exemption from some new requirements under the Patient Protection and Affordable Care Act. Under the amended regulation, a group health plan may now switch insurance companies and maintain its grandfathered plan status as long as it adheres to other requirements outlined in this and the original regulation. This amendment affords employers more flexibility in shopping for health plans that offer coverage at a lower cost. Additional information regarding this provision is available at: http://www.hhs.gov/news/press/2010pres/06/20100614e.html.

New Regulation Outlining Changes to Medicare Program

This regulation, issued on November 24, 2010, outlines several changes to the Medicare program regarding the following: (1) the hospital outpatient prospective payment system, (2) the ambulatory surgical center payment system, (3) payments to hospitals for graduate medical education (GME) costs and indirect medical education (IME) costs, (4) rules governing physician self-referrals and related provider agreements in hospitals where physicians have investment interests or in hospitals owned by physicians, and (4) payments for certified registered nurse anesthetist services in rural and critical access areas. Changes to the hospital and ambulatory surgical centers payments systems will be to the amounts and factors used to determine payment rates. For both GME and IME hospital payments this regulation implements new provisions under the Patient Protection and Affordable Care Act. With respect to physician self-referrals, this regulation introduces new limitations. And as to anesthesia services there will be changes to the effective date of when hospitals can begin receiving reasonable cost payments for these services.

CMS Issued Stark Self-Disclosure Protocol

On September 23, 2010, the Center for Medicare and Medicaid Services (CMS) announced a disclosure protocol pertaining to Stark Law self-referrals in accordance with Section 6409 of the Patient Protection and Affordable Care Act (PPACA). The purpose of the Medicare self-referral disclosure protocol (SRDP) is to create a mechanism that affords both health care providers and suppliers the opportunity to disclose either real or potential violations of the Stark law. In the event of a violation, a provider’s or supplier’s submission of this information to CMS may potentially result in a reduction in the amount due for the self-referral violations. For additional information regarding the SRDP, please go to the following website: http://www.cms.gov/PhysicianSelfReferral/65_Self_Referral_Disclosure_Protocol.asp

Alert: CMS’s Stark Law Self-Referral Disclosure Protocol Raises Tough Decisions for Healthcare Providers

On September 23, 2010, the Center for Medicare and Medicaid Services (CMS) announced a disclosure protocol pertaining to Stark Law self-referrals in accordance with Section 6409 of the Patient Protection and Affordable Care Act (PPACA). The purpose of the Medicare self-referral disclosure protocol (SRDP) is to create a mechanism that affords both health care providers and suppliers the opportunity to disclose either real or potential violations of the Stark law. In the event of a violation, a provider’s or supplier’s submission of this information to CMS may potentially result in a reduction in the amount due for the self-referral violations. For additional information regarding the SRDP, please go to the following website: http://www.cms.gov/PhysicianSelfReferral/65_Self_Referral_Disclosure_Protocol.asp

Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the PPACA

This regulation outlines the requirements for the following processes of group health plans and health insurance coverage in the group and individual market: (1) internal claims and appeals, and (2) the external review processes. These updated processes become effective for plan years (policy years in the individual market) beginning on or after September 23, 2010. Key provisions of this regulation include: how insurers can comply with the new internal claims and appeals process, guidance for external review processes and whether insurers must follow state or federal procedures, and notice requirements for appeals processes. This regulation is not applicable to grandfathered group health plans.

Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under PPACA

This regulation outlines requirements for group health plans and health insurance coverage in the group and individual markets for two areas: (1) expansion of coverage of recommended preventive services, and (2) restrictions on or prohibition of the implementation of cost-sharing mechanisms by the insurers (i.e. coinsurance, deductibles and copayments). These requirements generally become effective for plan years (policy years in the individual market) beginning on or after September 23, 2010. A list of recommendations and guidelines for insurers with respect to preventative services is available at: http://www.HealthCare.gov/center/regulations/prevention.html

Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the PPACA; Interim Final Rule and Proposed Rule

This regulation outlines the requirements for dependent coverage of children until the attainment of 26 years of age by their parents’ group health plans and health insurance issuers in the group and individual markets. This regulation also contains information regarding whether this provision preempts existing state laws that have different age limitations. Eligible dependents may be enrolled no earlier than the first day of the first plan year (policy years in the individual market) beginning on or after September 23, 2010.