Tag Archives: patient protection and affordable care act

Alternative Provider Reimbursement Models – How Are They Treated Under MLR Rules?

by Joseph J. Kempf, Jr., and Jackie Selby

Evolving reimbursement models for health care providers (away from “fee for service” and toward “pay for performance” and risk sharing) raise interesting questions as to how such payments will be treated under the new medical loss ratio rules under the Patient Protection and Affordable Care Act. Some of the payments will not qualify as “medical expense” or “quality improvement activities” and will be treated as “administrative expense,” so providers and insurers and health plans may want to take these rules into account when structuring alternative reimbursement methodologies.

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ACA Decision Should Not Delay Employer Prep for 2014

by Jay P. Krupin and Adam C. Solander

Since oral arguments ended at the U.S. Supreme Court, the media has been held captive by the predictions of attorneys and pundits as to the outcome. What most of these predictions have failed to capture, however, is that from an employer perspective, the Supreme Court’s decision is unlikely to have any significant impact on the applicability of the Patient Protection and Affordable Care Act (“ACA”). As a result, the court’s decision should not affect an employer’s preparation moving forward.

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The Supreme Court Mulls Obamacare; The Health Care Industry Mulls The Supreme Court

By Stuart M. Gerson

The three days of arguments about the constitutionality of the Patient Protection and Affordable Care Act are complete. The Justices of the Supreme Court of the United States have conducted their post-argument conference and are now turning their attention to the drafting and the discussions that will lead to a majority opinion and, likely, several dissents and concurrences. The Court’s decision should be issued before the end of June. Health care companies and employers, like the rest of the population, await the ultimate decision. However, there are several matters that can be identified in the short run.

A link to this Implementing Health and Insurance Reform publication is attached here: http://www.ebglaw.com/showclientalert.aspx?Show=15893

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HEALTH REFORM: Status Report on the Federal Health Insurance Rate Review Program

The Patient Protection and Affordable Care Act (“Affordable Care Act“) required the U.S. Department of Health and Human Services (“HHS“) to establish a process for the review of “unreasonable” health insurance premium rate increases in the individual and small group markets. As a result, federal regulations mandating the review of all rate increases of 10 percent or more in the individual and small group markets became effective on September 1, 2011.[1]

In the six months since the federal rate review regulations became effective, the Center for Consumer Information & Insurance Oversight (“CCIIO“) in the Centers for Medicare & Medicaid Services (“CMS“)[2] has completed 22 reviews of insurance premium rate increase filings. CCIIO determined that six of the reviewed premium rate increases represented “unreasonable” increases while 16 of the rate increases were deemed “not unreasonable.” It is our understanding that none of the filed rates that CCIIO deemed “unreasonable” have been rescinded or otherwise adjusted.

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PPACA-"Cert. Worthy"

In accordance with the briefing schedule issued last December, initial briefs have been filed with the U.S. Supreme Court for its judicial review of certain issues under the Patient Protection and Affordable Care Act of 2010 (“PPACA”).  The issues to be reviewed by the Court include whether (i) the minimum coverage provisions under PPACA and individual mandate to buy health insurance is a valid exercise of Congress’ power under Article I of the U.S. Constitution, (ii) the Anti-Injunction Act will prevent a ruling from the Court until such time as a tax is actually collected under PPACA, (iii) the individual mandate, if found unconstitutional, is severable from PPACA so that the law’s other provisions can be upheld, and (iv) Medicaid expansion is constitutional.

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IRS Seeks Comment from Employers on Definition of Full Time Employee Under the Affordable Care Act

By: Kara Maciel and Adam Solander

Over a year after thePatient Protection and Affordable Care Act (“PPACA”) was signed into law, the Internal Revenue Service (“IRS”) recently released much anticipated information on issues related to the calculations of full-time and full-time equivalent employees for determining when an employer may be subject to a penalty under PPACA. In Notice 2011-36 (“Notice”), the IRS is specifically seeking employer’s comments on several of the issues by June 17, 2011. For hospitality employers, who traditionally employ a large number of part-time, temporary, and seasonal workers, the Notice provides an excellent opportunity for employers to comment and potentially alter PPACA’s financial impact in 2014.       

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Meeting the Requirements for Defining the “Essential Health Benefits Package:” DOL Publishes Survey of Employer-Sponsored Coverage

by Lynn Shapiro Snyder, Clayton J. Nix, and Lesley R. Yeung

The U.S. Department of Labor (“DOL”) released a survey report on April 15, 2011, that is being used to satisfy a requirement in the Patient Protection and Affordable Care Act (“ACA”) that the Secretary of Labor “conduct a survey of employer-sponsored coverage” as a condition precedent to the development of the “essential health benefits package” by the Secretary of Health and Human Services (“HHS”). This DOL survey is the first step in the process laid out in ACA for establishing the minimum benefits package to be offered in the various health insurance exchanges for which subsidies and tax credits will be available. Under ACA, the Secretary of HHS ultimately has the discretion for determining the “essential health benefits package,” which goes to the heart of federal health reform. Companies that are interested in the scope of the “essential health benefits package” will want to review not only this published DOL survey in detail, but also other DOL survey information, and should consider weighing in with the Secretary of HHS before any preliminary positions are published by HHS in proposed or interim final regulations.

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Liz Sullivan featured in "Proposed Rules for the State Innovation Application Process Released by the Departments of Health and Human Services…

Liz Sullivan was featured in “Proposed Rules for the State Innovation Application Process Released by the Departments of Health and Human Services and Treasury Issue,” published by RBMA.

Proposed Rules for the State Innovation Application Process Released by the Departments of Health and Human Services and Treasury Issue
By: Liz Sullivan

The Departments of Health and Human Services and the Treasury recently issued a set of proposed rules outlining how states may apply for “Innovation Waivers.” Innovation Waivers would exempt states from many of the requirements of the Patient Protection and Affordable Care Act (ACA). The proposed rules follow a year of state challenges to the ACA as well as increasing efforts by Republicans to repeal the ACA. Under the ACA, states are not eligible to obtain innovation waivers until 2017; however a new bi-partisan bill supported by President Obama would make state waivers available as early as 2014.

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HEALTH REFORM: Meeting the Requirements for Defining the "Essential Health Benefits Package": DOL Publishes Survey of Employer-Sponsored Coverage

On April 15, 2011, the U.S. Department of Labor (“DOL”) released a survey report that is being used to satisfy a requirement in the Patient Protection and Affordable Care Act (“ACA”) that the Secretary of Labor “conduct a survey of employer-sponsored coverage” as a condition precedent to the development of the “essential health benefits package” by the Secretary of Health and Human Services (“HHS”).[1] This DOL survey is the first step in the process laid out in the federal health reform law for establishing the minimum benefits package to be offered in the various health insurance exchanges for which subsidies and tax credits will be available. Under ACA, the Secretary of HHS ultimately has the discretion to determine the “essential health benefits package,” which goes to the heart of federal health reform by providing an adequate level of health insurance coverage to the uninsured and underinsured. That discretion is limited by certain conditions and requirements set forth in ACA.

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Whistleblowing Takes New Turn with Mandated Reporting Imposed by PPACA’s Elder Justice Act

By: Allen B. Roberts, Victoria M. Sloan

The typical set of protections or awards featured in a familiar array of whistleblower statutes has a new entrant with the imposition of mandated reporting in the Elder Justice Act section of the recently enacted Patient Protection and Affordable Care Act (“PPACA”). In a notable departure from other laws, the Elder Justice Act provides that every individual employed by or associated with a long-term care facility as an owner, operator, agent or contractor has an independent obligation to report a “reasonable suspicion” of a crime affecting residents or recipients of care. Reports must be made directly to both the Secretary of Health and Human Services (“HHS”) and one or more law enforcement entities in as little as two hours following the formation of the reasonable suspicion.

Although limited to reports of crimes against residents and recipients of services of long-term care facilities, the mandate of the Elder Justice Act sets a new standard of conduct – and backs it up with stiff penalties affecting long-term care facilities and those associated with them.

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