Congress returns from its Memorial Day recess to four full weeks of legislative activity. The drama of the American Health Care Act (AHCA) now hangs over the Senate. The House will return to its regular work once they advance the FDA User Fee Reauthorization, with the Senate also having to schedule floor time for the package. Also on our radar this month will be the date June 21st– the date in which insurers decide if they will participate in the Obamacare Marketplace for 2018. This could play a role in the Administration’s ongoing discussions regarding cost-sharing reductions, as well as how the Senate approaches its version of the AHCA. Continue Reading Congress Returns for June Session to Face AHCA, User Fees and More

Last week, the Centers for Medicare & Medicaid Services (“CMS”) released its 2018 Notice of Benefit and Payment setting out payment parameters for the Health Insurance Marketplace for upcoming years.  With several insurers withdrawing from the Marketplace and others still threatening their departure, CMS is releasing this proposed Notice nearly two months early with significant proposals seeking to strengthen the program.

At the core of CMS’s proposals to strengthen the Marketplace are updates to the HHS risk adjustment model and methodology.  Specifically, CMS is proposing: (1) an adjustment for members who are only enrolled for part of the year; (2) the inclusion of select prescription drug utilization data in the risk adjustment model; and (3) modifications to establish transfers for costs associated with high-cost enrollees so a portion of the costs exceeding $2 million for an individual would be shared among all issuers. Continue Reading 2018 Notice of Benefits and Payment: Proposed Updates to the HHS Risk Adjustment Model

Earlier this month, the Court of Appeals for the D.C. Circuit issued its decision in Central United Life Insurance Co., v. Burwell, striking down a Department of Health and Human Services (HHS) rule prohibiting the sale and marketing of “fixed indemnity” plans to consumers who did not otherwise have minimum essential coverage. While at first pass the case focuses on a small set of insurance policies, this decision could have broader implications on the individual market and further threaten the sustainability of the risk pools.

This case focused on “fixed indemnity” policies, which are insurance products that pay out a fixed amount for each medical event, regardless of the actual cost of the service (e.g., the policy pays $100 per physician visit). Fixed indemnity policies are considered “excepted benefits” under the Public Health Service Act (PHSA), so long as (i) they are “provided under a spate policy, certificate, or contract of insurance,” and (ii) “are offered as independent non-coordinated benefits.” The Affordable Care Act (ACA) explicitly excluded excepted benefits from minimum essential coverage. Continue Reading D.C. Circuit Strikes a Potential Blow to the Affordable Care Act

Written by Julie E. Korostoff and Christine M. Wahr

The flow of traffic on HeathCare.gov on Tuesday, October 1, described by a representative from the Centers for Medicare & Medicaid Services (“CMS”) as “historic,” reportedly reached up to 2.8 million users, as individuals visited the new “federal “health insurance marketplace – formerly referred to as the federal health exchange (“Exchange”) – which forms the core of Affordable Care Act (“ACA”) implementation.   By Friday night, nearly nine million unique consumers had reportedly visited the site.  But while the opening marked a significant step forward in implementation of the ACA, the accomplishment was overshadowed almost instantly as users encountered technological glitches with the Exchange, which serves as a portal for 36 states. Among the 14 states, including Vermont, Maryland, and the District of Columbia that launched their own exchanges that rely on the federal system, performance has been mixed, with certain states reporting successfully enrolled individuals and others reporting similar technological problems. Continue Reading Health Insurance Marketplace Implementation Continues