Eligibility of AI/ANs with Incomes Under 100 Percent FPL for CSRs
CCIIO (no reference number)
AGENCY: CCIIO
Clarification of Eligibility of American Indians and Alaska Natives with Incomes Under 100 Percent of the Federal Poverty Level for Cost-Sharing Reductions
Released: 8/14/2015
Due date: None
|
This letter, sent in response to concerns raised in a letter submitted by tribal organizations on June 26, 2015, clarifies the eligibility of AI/ANs with household incomes less than 100 percent of the federal poverty level for cost-sharing reductions in qualified health plans. According to this letter, AI/ANs of any income level qualify for enrollment in the limited cost-sharing plans. This letter also states that Marketplaces automatically enroll AI/ANs who do not request an eligibility determination into limited cost-sharing plans.
A copy of this letter is embedded below.
NIHB and TTAG submitted a letter to CCIIO on August 4, 2015, to request confirmation that eligibility determinations for Indian-specific cost-sharing protections are made consistent with ACA and implementing regulations and to raise other related concerns. A summary of the recommendations from tribal organizations, as well as the responses from CCIIO in this reply letter, appears below.
-
Eligibility: CCIIO should--
-
Audit the eligibility determination algorithm used by the Federally-Facilitated Marketplace (FFM) to confirm implementation of the eligibility determinations for the two Indian-specific cost-sharing variations (CSVs) in the application computer program and the determination process according to federal regulations and discuss the findings with TTAG.
-
Indicate on the FFM determination letters the specific cost-sharing variation for which an Indian applicant has qualified (the “02” or “03” CSV) and provide a summary description of the relevant Indian-specific CSV.
Response: According to CCIIO, “although the limited cost-sharing plan variation is sometimes described as one suitable for Indians with household incomes greater than 300 percent of the FPL, enrollment in the limited cost-sharing plan variation is generally available to Indians of any income, including those with household incomes below 100 percent of the FPL and above 400 percent of the FPL, who are not eligible for premium tax credits.” CCIIO added, “Thus, the Marketplaces do not require a financial eligibility determination for Indian applicants for the limited cost-sharing plan variation under 45 CFR 155.350(b), the Special cost-sharing rule for Indians regardless of income. The Marketplaces automatically enroll American Indians and Alaska Natives applicants who do not request an eligibility determination into limited cost-sharing plan variations, as required under this regulation.
-
General Protections: CCIIO should--
-
Increase education of qualified health plan (QHP) issuers on Indian-specific cost-sharing protections by:
-
Providing language on the Indian-specific CSVs for inclusion in QHP Summary of Benefits and Coverage documents due by October 2015.
-
Requiring issuers to indicate on their insurance cards the type of CSV applicable to the enrollee.
-
Communicate the availability of the Health Insurance Complaint System (HICS) and permit tribal sponsors of enrollees to submit multiple (repeat) cases involving a single QHP but multiple QHP enrollees in one HICS submission.
-
Ensure QHP issuers apply the Indian-specific CSVs correctly, drawing upon filings through HICS to identify erroneous application of Indian-specific CSVs, and prioritize conducting broader audits of the application of Indian-specific CSVs.
Response: CCIIO did not address this issue.
-
Payments to Indian Health Care Providers: CCIIO should--
-
Ensure QHP issuers make full payments to Indian health care providers, without deducting waived cost-sharing amounts.
-
Communicate availability of HICS and permit providers to submit multiple (repeat) cases involving a single QHP in one submission.
Response: CCIIO did not address this issue.
-
Shorthand Descriptions of Indian-Specific CSVs: CCIIO should consider adopting one or more of the following abbreviated descriptions for use by CMS when it requires a shorthand version of the explanation of the Indian-specific CSV--
00 - Non-Exchange variant
01 - Exchange variant (no CSR)
02 - Open to Indians between 100% and 300% FPL
03 - Open to Indians of any income level, or income not determined
04 - 73% AV Level Silver Plan CSR
05 - 87% AV Level Silver Plan CSR
06 - 94% AV Level Silver Plan CSR”
-
“02” or “Zero cost-sharing variation” protections are available to persons who meet the ACA’s definition of Indian, have household income between 100 and 300 percent FPL, are eligible for premium tax credits, and enroll in coverage through a Marketplace.
-
“03” or “Limited cost-sharing variation” protections are available to persons who meet the ACA’s definition of Indian, have any household income level, and enroll in coverage through a Marketplace.
-
Persons eligible for the limited cost-sharing variation do not have to be eligible for premium tax credits and can decide to not request an eligibility determination for insurance affordability programs (e.g., premium tax credits).
-
“Zero cost-sharing variation” (“02”)
Protections available to persons enrolled in coverage through a Marketplace who:
-
Meet the ACA’s definition of Indian
-
Have household income between 100 and 300 percent FPL
-
Qualify for premium tax credits
-
“Limited cost-sharing variation” (“03”)
Protections available to persons enrolled in coverage through a Marketplace who:
-
Meet the ACA’s definition of Indian
-
Have household income of any level
-
Do or do not qualify for premium tax credits
To receive the “02” or “03” protections, an individual cannot be enrolled in a family plan with individuals who are not eligible for the “02” or “03” protections.
Response: CCIIO did not address this issue.
|
8/15/2015: CMS response to the TTAG request was consistent with one of the Tribal recommendations: Confirm eligibility for the “03” or “limited cost-sharing variation”. CMS responded that the “03” or “limited cost-sharing variation” (LCSV) is available to all AI/ANs meeting the definition of Indian under the ACA who enroll in coverage through a Marketplace, regardless of income or eligibility for premium tax credits.
Two other requests from TTAG are outstanding: (1) confirm eligibility determinations are being made correctly and (2) include information on the Marketplace determination letters that individuals determined eligible for the 03 LCSV are in fact enrolled in a LCSof a selected plan.
No response required.
|
|
|
|
|
2016 Reenrollment in the FFM
CCIIO (no reference number)
AGENCY: CCIIO
Bulletin 16: Guidance for Issuers on 2016 Reenrollment in the Federally-Facilitated Marketplace (FFM)
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016AutoReenrollmentBulletin16.pdf
|
Released: 8/25/2015
Due Date: None
|
This bulletin provides guidance on the reenrollment process for 2016 Health Insurance Marketplace (Marketplace) coverage for issuers in Federally-Facilitated Marketplaces (FFMs). Specifically, this bulletin will replace “Bulletin #14: Guidance for Issuers on 2015 Reenrollment in the FFM,” released on December 1, 2014, and highlight changes in the 2016 reenrollment process for FFMs. While much of the redetermination and reenrollment process remains unchanged for the Annual Open Enrollment Period (OEP) for 2016, important changes include: (1) establishing eligibility for 2016 advance payments of the premium tax credit (APTC) and income-based cost-sharing reductions (CSRs) using the most recent family income data available and updated 2016 qualified health plan (QHP) prices (in contrast to the 2015 plan year, when 2014 APTC and CSRs were generally carried forward); (2) discontinuing APTC and income-based CSRs for enrollees who do not comply with the requirement to file a tax return and reconcile APTC for tax year 2014; (3) sending the first group of passive reenrollment transactions to issuers before the start of 2016 OEP; and (4) maintaining the 2015 effectuation status of enrollees in 2016 passive reenrollment transactions.
|
8/26/2015: No comments requested. Review of the document is in process.
|
|
|
|
|
Letter on Alaska Medicaid Expansion Plans
HHS (no reference number) [Discussion of application of 100% FMAP]
AGENCY: HHS
Letter from HHS Secretary Sylvia Burwell to Alaska Governor Bill Walker on Medicaid Expansion Plans
|
Released: 8/31/2015
Due Date: No specific date identified.
|
This letter, sent from HHS Secretary Sylvia Burwell to Alaska Governor Bill Walker, responds to several questions Walker raised regarding plans to expand the state Medicaid program. In this letter, Burwell addresses the issues of expansion readiness, support for continuation of reform and sustainability efforts, and funding opportunities.
The primary outstanding issue discussed in the letter is the application of 100 percent federal financial participation (FFP) to services provided by or through Indian health care providers.
A copy of this letter is embedded below.
Summation of Issue: A summary of the pending issue was provided by Elliot Milhollin: “The letter is a very important step forward for Alaska, but CMS is contemplating going even further. Under CMS’ existing interpretation of the rule, 100 percent FMAP applies to (1) all services provided within an IHS or tribal facility; (2) services provided by other providers within those facilities through arrangements (i.e, contracts) with outside providers; and (3) even covers services provided beyond the four walls of the facility through contractual arrangements, so long as the service is billed by the facility itself (i.e., contracts with outside specialists like teleradiology, etc.). Contract health services are not covered under its existing interpretation, however.
In 2011, CMS issued a letter to Arizona confirming that CMS’ existing policy allowed non-emergency transportation to be covered under its existing policy under these conditions.
The waivers proposed in OK, SD and AK have given CMS the opportunity to revisit its interpretation. SD, for example, has proposed expanding Medicaid if CMS allows CHS to be reimbursed at 100 percent FMAP due to the cost savings that would result to the State.
CMS is now considering whether to revise its interpretation so that it would cover Contract Health Services (Purchased/Referred Care). CMS is actively seeking consultation from tribes on whether or not to do so. It has consulted with AK and OK tribes on the issue, and will also be consulting with SD tribes. The CMS tribal consultation to be held prior to the NIHB meeting is the opportunity for Tribes (and TTAG) to urge CMS to revise its interpretation so that it covers CHS.
This is an enormously significant development, and I would recommend it be a priority issue for TTAG on our next call to prepare for the consultation at NIHB.”
|
9/3/2015: The primary outstanding issue discussed in the letter is the application of 100 percent federal financial participation (FFP) to services provided by or through Indian health care providers.
Additional efforts on expanding the application of 100% FFP to additional services are underway in Oklahoma, South Dakota and (possibly) Wyoming.
Tribal representatives might wish to discuss these various efforts.
|
|
|
|
|
SBC Online Posting of Policy and Certificate of Coverage Documents
CCIIO (no reference number)
AGENCY: CCIIO
Summary of Benefits and Coverage Online Posting of Policy and Certificate of Coverage Documents
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/SBCPolicyCertificateCovFAQs.pdf
|
Released: 9/8/2015
Due Date: None
|
This guidance answers the following frequently asked questions regarding online posting of summary of benefits and coverage (SBC) documents:
-
Q1. When must individual and group health insurance issuers make individual coverage policy and group certificate of coverage documents, respectively, accessible online under PHS Act section 2715 and final regulations?
A1. Under PHS Act section 2715(b)(3)(i) and the final rules published on June 16, 2015, health insurance issuers must include an Internet web address where the actual individual coverage policy or group certificate of coverage can be reviewed and obtained on the Summary of Benefits and Coverage (SBC). ... It has come to HHS’ attention that some issuers have encountered certain difficulties making these documents accessible online by these dates, given that this is the first time for this process. ...
To the extent an issuer is unable to meet this requirement by the applicability dates listed above, HHS will not take enforcement action against an issuer that makes the individual coverage policy or group certificate of coverage documents accessible online no later than November 1, 2015. This relief is limited to the requirement to post the individual coverage policy or group certificate of coverage. Issuers must still provide the SBC in accordance with the timeframes set forth in the final rules. Issuers must provide on the SBC the web address where the documents will be available by November 1, 2015, and must include language on the web page indicating the documents will be accessible on November 1, 2015.
We clarify that under the applicability date provisions in the final rule, with respect to individual market coverage, the requirements apply with respect to SBCs issued for coverage beginning on or after Jan. 1, 2016, therefore issuers are not expected to make an internet web address to access the individual coverage policy documents available for coverage that begins before January 1, 2016. We further clarify that if a group health insurance issuer is required, in accordance with the June 12, 2015, SBC final rule, to provide the internet web address on the SBC before October 31, 2015, HHS will not take enforcement action against that issuer if it provides an internet web address for group certificate of coverage documents no later than November 1, 2015. Beginning on November 1, 2015, as stated above, all group and individual health insurance issuers are expected to provide an internet web address for the group certificate of coverage or individual policy documents, respectively, by the date which the SBC is otherwise required under the final rules.
As stated in the preamble to the June 16, 2015, final rules, an issuer required to provide an internet web address is permitted to satisfy this requirement with respect to plan sponsors that are shopping for coverage by posting a sample group certificate of coverage for each applicable product. After the actual certificate of coverage is executed, it must be easily available to plan sponsors and participants and beneficiaries via an internet web address.
This relief is only applicable with respect to the requirement to make individual coverage policy and group certificate of coverage documents accessible online, and does not apply to any other requirements of the June 16, 2015, final rules.
-
Q2. In the preamble to the June 16, 2015, final rules, the Departments of HHS, Labor, and the Treasury provided enforcement relief for coverage that is no longer being offered for purchase (closed blocks of business) provided that certain conditions are met. Closed blocks of business that satisfy the conditions are not required to provide an SBC. Are health insurance issuers required to provide an internet web address for individual coverage policy or group certificate of coverage documents with respect to closed blocks of business that do not satisfy the closed blocks safe harbor criteria?
A2. Closed blocks of business that do not meet the conditions for enforcement relief must continue to comply with the SBC requirements, including providing the SBC to plan sponsors and individuals at the required timeframes in the SBC final rules. HHS recognizes a concern that consumers shopping for coverage might access the individual coverage policy or group certificate of coverage documents for a closed block of business in which they are not eligible to enroll; this could lead to consumer confusion and frustration. Therefore, HHS will not take enforcement action against an issuer of a closed block of business that does not satisfy the safe harbor criteria that limits access to the individual coverage policy or group certificate of coverage documents to plan sponsors that have already purchased and individuals who are currently enrolled in the coverage.
|
9/9/2015: No response requested or recommended.
|
|
|
|
|
FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace
CCIIO (no reference number)
AGENCY: CCIIO
Frequently Asked Questions (FAQs) Regarding Agents and Brokers Operating in the SHOP Marketplace
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Frequently-Asked-Questions-AB-SHOP-91815.pdf
|
Released: 9/18/2015
Due Date: None
|
This guidance answers the several frequently asked questions regarding agents and brokers operating in the SHOP Marketplace.
|
9/15/2015: No comments requested or recommended.
|
|
|
|
|
FAQs Regarding the FFM 2016 Employer Notice Program
CCIIO (no reference number)
AGENCY: CCIIO
Frequently Asked Questions Regarding The Federally-Facilitated Marketplace’s (FFM) 2016 Employer Notice Program
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Employer-Notice-FAQ-9-18-15.pdf
|
Released: 9/18/2015
Due Date: None
|
This guidance answers a number of frequently asked questions regarding the Federally-Facilitated Marketplace (FFM) 2016 Employer Notice Program.
|
|
|
|
|
|
Adjustment to the Amount in Controversy Threshold in Medicare Appeals for CY 2016
CMS-4178-N
AGENCY: CMS
Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2016
http://www.gpo.gov/fdsys/pkg/FR-2015-09-25/pdf/2015-24359.pdf
|
Released: 9/25/2015
Due Date: None
|
This notice announces the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will apply to requests for ALJ hearings and judicial review filed on or after January 1, 2016. The calendar year 2016 AIC threshold amounts are $150 for ALJ hearings and $1,500 for judicial review.
|
|
|
|
|
|
Periodic Data Matching in the FFM
CCIIO (no reference number)
AGENCY: CCIIO
Periodic Data Matching in the Federally-Facilitated Marketplaces (Marketplaces) FAQ
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Periodic-Data-Matching-FAQ-92815.pdf
|
|
