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Regulatory Resource for Actuaries: Health


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Last reviewed: 7/16/2019

Recent Updates

 

Affordable Care Act (ACA)

2018 Tax Bill Tax Bill Impacts ACA Individual Mandate
The Tax Cuts and Jobs Act effectively removed the penalty for the individual mandate under the Affordable Care Act by reducing the penalty to zero. The Tax Cuts and Jobs Act removed the penalty for the individual mandate under the Affordable Care Act effective January, 1 2019.

Suspension of Certain Health-Related Taxes H. R. 195 SEC. 4003
This law suspends the annual fee on health insurance providers for the calendar year 2019. It also extends the moratorium on the medical device excise tax and delays the implementation of the excise tax on high-cost employer-sponsored health coverage until 2022.

 

CCIIO

CCIIO’s QHP Information (includes Templates and Instructions Links)
A QHP insurance plan is certified by the Health Insurance Marketplace, provides EHBs, follows established cost-sharing limits and meets requirements outlined within the application process. The 2018 QHP Application is available to issuers applying for certification to participate in the FFMs. (One web page)

CCIIO: SHOP Implementation of Vertical Choice
CIIO finalized the new ‘‘vertical choice’’ model for FF-SHOPs and State-based Exchanges using the Federal platform for SHOP eligibility and enrollment (SBE-FP). For plan years beginning on or after January 1, 2017, employers will offer qualified employees a choice of plans across all available actuarial value levels from a single issuer. (3 web pages)

CCIIO Draft 2020 Letter to Issuers in the Federally-facilitated Marketplaces
CMS released Draft 2020 Letter to Issuers in the Federally-facilitated Marketplaces to provide issuers seeking to offer QHPs, including SADPs, in the FFMs or FF-SHOPs with operational and technical guidance to help them successfully participate in any such Marketplace SM in 2020. (Posted 2/2019)

CCIIO: Rate Review Data

The ACA and rate review regulation require review of increases of 10 percent or more. CMS reviews rate increases in states with no effective rate review program. This page contains links to the rate review data posted on the CCIIO website, including Parts I, II, and III of the Preliminary Justification. (1 web page)(Posted 10/2018)

Final 2020 Actuarial Value Calculator
The Actuarial Value Calculator (AV Calculator) is designed to give an estimate of the actuarial value for  given plan design. This version uses data from a large national commercial database to build continuance tables by metal tier. (Posted 3/2019)

Final 2020 Actuarial Value Calculator Methodology
The methodology is published for review and understanding of the users. (Posted 2/2019)

Patient Protection and Affordable Care Act; Market Stabilization  
HHS adopted changes to stabilize the ACA market by amending guaranteed availability and timing of the annual open enrollment period in the individual market for the 2018 plan year; standards related to network adequacy; essential community providers for qualified health plans; and actuarial value rule requirements.” These regulations became effective on June 19, 2017. (Posted 2/2018)

Proposed List of Key Dates for CY 2019 for QHP Certification, Rate Review, Risk Adjustment and Reinsurance
Key dates for QHP Certification in the Federally-facilitated Marketplaces for coverage effective on or after January 1, 2020; Rate Review for Single Risk Pool coverage effective on or after January 1, 2020; Risk Adjustment and Reinsurance for Benefit Year 2019. (3 pages) (Posted 2/2019)

Section 1332: State Innovation Waivers
CMS provides resources for section 1332 waivers which states can apply to pursue innovative strategies for providing their residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA. (3/2019)

Update on the HHS-operated Risk Adjustment Program for the 2017 Benefit Year
After a federal court decision vacating the use of statewide average premium in the HHS-operated risk adjustment transfer formula for the 2014 – 2018 benefit years, CMS suspended risk adjustment payments and charges. CMS has released the Adoption of the Methodology for the HHS-operated Permanent Risk Adjustment Program under the Patient Protection and Affordable Care Act for the 2017 Benefit Year final rule. This allows HHS to resume 2017 benefit year risk adjustment operations. (Posted 8/2018)

2019 Unified Rate Review Instructions: Rate Filing Justification: Parts I, II, and III
Issuers offering non-grandfathered small group and/or individual markets health insurance coverage submit rate increases to CMS. Rate Filling Justifications (RFJ) must provide information for state or federal regulators to review filings for compliance. CMS may use data submitted to calculate APTC and CSR advance payments. (73 pages) (Posted 4/2018)

 

Court Cases

Common Residential Treatment Claims Practices Determined Not Compliant with Mental Health Parity: Danny P. v Catholic Health Initiatives
Although the interim final rules did not address the scope of services, the Ninth Circuit Court of Appeals found that congruency between behavioral health and medical/surgical benefits is required within a classification and that excluding room and board for residential treatment facilities is an improper treatment limitation when such services are covered for skilled nursing facilities. (Posted 01/2019)

DC District Court: The American Hospital Association v Azar
The Court ruled that The Department of Health and Human Services overstepped its statutory authority when it cut Part B drug reimbursement rates for providers who obtain drugs at a discount by participating in Medicare’s 340B program. (Posted 12/2018)

DC District Court: State of New York v DOL
The court ruled that the DOL unreasonably expanded the definition of “employers” to include groups without any real commonality of interest and to bring working owners without employees within ERISA’s scope. The Final Rule’s bona fide association and working owner provisions were therefore vacated. (Posted 4/2019)

Religious Groups and Contraception Coverage in ACA Supreme Court: Zubik v Burwell
Nonprofit organizations challenged a mandate to provide health insurance to employees that cover contraceptives, or submit a form, objecting on religious grounds. Petitioners alleged that submitting this notice substantially burdens the exercise of their religion. The Supreme Court sent the cases back to the Courts of Appeals "to resolve any outstanding issues between them.” (9 pages)  (Posted 05/2016)

Supreme Court: King v Burwell
The ACA requires the comparison and purchase of insurance plans (“Exchange”) in each state, which can establish its own Exchange. Petitioners do not want to purchase health insurance but would receive tax credits to reduce the cost of buying insurance, subjecting them to the ACA’s coverage requirement. Petitioners challenged the IRS Rule. The District Court dismissed the suit and the Court of Appeals for the Fourth Circuit affirmed as did the SCOTUS in a 6-3 decision. (47 pages) (Posted 05/2016)

Supreme Court: National Federation of Independent Business v Sebelius
The ACA expands the scope of Medicaid and increases federal funding to cover the States’ costs. If a State does not comply with the requirements, it may lose federal funding, including all of its Medicaid funds. The plaintiffs brought suit challenging the constitutionality of the individual mandate and Medicaid expansion. SCOTUS upheld the individual mandate as within Congress’s power under the Taxing Clause. (193 pages) (Posted 12/2012)

 

Pricing

AAA Individual and Small Group Markets Committee  
An issue brief from the American Academy of Actuaries on the drivers of 2018 Health Insurance Premium Changes (2 pages) (Posted 5/2017)

NCSL: Mandated Health Insurance Benefits and State Laws    
The home page included Mandated Health Insurance Benefits and State Laws, Essential Health Benefits, 50-State Table of Essential Health Benefits Benchmarks for 2016 and 2017, State Mandate Studies and Evaluations, Tables and other documents. The site provides internal and external links on various coverage types. The page also includes links to Related Reports from NCSL. (One webpage) (Posted 12/2015)

 

Risk Adjustment

ACA Interim Risk Adjustment Report for CY 2018
The ACA establishes a permanent risk adjustment program to provide payments to health insurance issuers that attract high-risk enrollees. Premiums should reflect the differences in plan benefits, quality, and efficiency, not the health status of the enrolled population. CMS issued interim risk adjustment summary information for a state only if all credible issuers in that state passed both quantity and quality thresholds. (29 pages) (Posted 3/2019)

Summary Report on Permanent Risk Adjustment Transfers for the 2018 Benefit Year
Section 1341 of the ACA a permanent risk adjustment program. The program is designed to provide issuers with greater payment stability as the insurance market reforms are implemented and the Marketplaces facilitates increased enrollment. This year also includes the high-cost risk pool charge for the individual and small group markets. (33 pages) (Posted 7/2019)

CCIIO’s Risk Adjustment Discussion Paper 
The HHS-Operated Risk Adjustment Methodology Meeting Discussion Paper provides a summary of the risk adjustment methodology, including detailed explanations of the risk adjustment models, the payment transfer formula, and updates to the model. The paper explored potential modifications to the risk adjustment methodology for the 2018 benefit year and beyond. (130 pages) (Posted 3/2016)

CMS Publishes 2017 Benefit Year HHS Risk Adjustment Data Validation Results
The Centers for Medicare & Medicaid Services (CMS) is making available summary information on issuers’ 2017 benefit year HHS risk adjustment data validation (HHS-RADV) results in .1. The 2017 benefit year HHS-RADV results will be used to adjust 2018 benefit year risk adjustment plan liability risk scores, resulting in an adjustment to 2018 benefit year risk adjustment transfer amounts. (Posted 06/2019)

Potential Updates to HHS-HCCs for the HHS-operated Risk Adjustment Program

CMS published potential changes coming to the 2021+ ACA risk adjustment model that includes modifications to its HHS-operated risk adjustment program for the individual and small group markets based on analysis of more recent data. (Posted 07/2019)

Change to Risk Adjustment Holdback for the 2018 Benefit Year and Beyond
HHS has announced a change to the holdback policy for the 2018 benefit year and beyond for the states where HHS operates the Risk Adjustment Program. Previously, CMS would hold back a certain percentage of risk adjustment payment amounts for sequestration and appeals. Under this new policy, CMS will release holdback amounts in the next applicable fiscal year without regard to any pending appeals and make any necessary post-calculation adjustments in the event an appeal is successful. (Posted 06/2019)

Do It Yourself Software Instructions
The link includes Tables (Excel) and Model Algorithm Software (Zip).

Final Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for CY
Section 1341 of the ACA established a transitional reinsurance program and a permanent risk adjustment program (in section 1343). The reinsurance program is designed to provide issuers with greater payment stability as the insurance market reforms are implemented and the Marketplaces facilitates increased enrollment. This report reflects the preliminary results. (59 pages) (Posted 8/2018)

Appendix A: HHS Risk Adjustment Program State-Specific Data
The Appendix provides state-specific data.

Appendix B: HHS Risk Adjustment Geographic Cost Factor
The Appendix provides risk adjustment of geographic cost factors.

Appendix C: Issuer-Specific Information for Individual and Small Group Markets (Table 3)
The Appendix provides issuer-specific information for individual and small group markets.

Appendix D: Issuer-Specific Information for Merged Market States (Table 4)
The Appendix provides issuer-specific information for merged market states.

Appendix E: Default Risk Adjustment Charge (Table 7)
The appendix provides Default Risk Adjustment Charge.

Appendix F: Default Risk Adjustment Charge Allocation (Table 8)
The Appendix provides a Default Risk Adjustment Charge Allocation.

 

Actuarial Standards Board – Actuarial Standards of Practice (ASOPs)

ASB Adopts ASOP 55 on Capital Adequacy Assessment for Insurers 
The ASB has adopted Actuarial Standard of Practice 55 regarding Capital Adequacy Assessment for Insurers. The effective date is November 1, 2019. (Posted 7/2019)

Second Exposure Draft of ASOP on Setting Assumptions Proposed  
The ASB has released a Second Exposure Draft on a proposed Actuarial Standard of Practice regarding Setting Assumptions. The comment period on the draft will close on July 31, 2019. (Posted 7/2019)

Proposed Modeling Expose Draft Approved   
The ASB recently approved a fourth exposure draft of a proposed new ASOP titled Modeling to provide guidance to actuaries in any practice area when performing actuarial services with respect to designing, developing, selecting, modifying, or using all types of models. The comment deadline for the fourth exposure draft, which can be viewed under the “Drafts” tab in “Current Exposure Drafts,” closed on May 15, 2019. (Posted 7/2019)

Actuarial Standard of Practice No. 5   
This revision of ASOP No. 5 reflects a number of changes to other standards that have been made since the 2000 revision, including updating the ASOP, where appropriate, to incorporate reference to new standards that have been issued since the 2000 revision, eliminate guidance that does not conform to current ASOP practices regarding references to other standards of practice, and make consistent the definitions used in the standard with those of other standards of practice. In addition, this revision of ASOP No. 5 has been updated to reflect relevant legal, regulatory, and practice developments that have occurred since the 2000 revision. (Effective 9/2017, Posted 3/2019)

ASOP No. 22 Revision Proposal -  Statements of Actuarial Opinion Based on Asset Adequacy Analysis for Life or Health Liabilities
Changes to the exposure draft include revising the purpose and scope in sections 1.1 and 1.2 from applying to actuaries when providing an SAO for life and health insurers to applying to actuaries when providing an SAO relating to asset adequacy analysis of life and health liabilities. The comment deadline for the exposure draft closed on June 1, 2019. (Posted 12/2018)

Actuarial Standard of Practice No. 42   
This document contains the final version of a revision of ASOP No. 42, Health and Disability Actuarial Assets and Liabilities Other Than Liabilities for Incurred Claims. (Effective 8/2018, Posted 3/2019) 

Emerging Regulations

Bill Proposed to Protect Patient Against Excess Costs of Out-of-Network Bills (Posted 12/2018)

 

Federal Register

Association Health Plans  - Final Rule to Change the Definition of Employer under Section 3(5) of ERISA
The final rule broadens the criteria for determining when employers may join together in an employer group or association. By treating the association itself as the employer, the regulation would facilitate the adoption and administration of such arrangements. The goal of the rule is to expand access to affordable health coverage, especially among small employers and self-employed individuals. (Posted 6/2018) 

E-CFR for Title 45: Requirements Relating to Health Care Access
Part 146 implements requirements of Title XXVII of the Public Health Service Act (PHS Act, 42 U.S.C. 300gg, et seq.) that apply to group health plans and group health insurance issuers. Part 147 implements the provisions of the Patient Protection and Affordable Care Act that apply to both group health plans and health insurance issuers in the Group and Individual Markets. Part 147 implements Individual Health Insurance Market requirements of the PHS Act.  (Posted 12/2018)

Excepted Benefits; Lifetime and Annual Limits; and Short-Term, Limited-Duration Insurance
This document defines short-term, limited-duration insurance and includes standards for travel insurance and supplemental health insurance to be considered excepted benefits. This document also amends a reference in the final regulations relating to the prohibition on lifetime and annual dollar limits. (Posted 10/2016)

Extended Non-Enforcement of ACA-Compliance With Respect to Certain Policies through 2020
The extended non-enforcement policy in this bulletin applies for policy years beginning on or before October 1, 2020, provided that all such coverage comes into compliance with the specified requirements by January 1, 2021. (Posted 4/2019)

Patient Protection and Affordable Care Act; HHS Final Notice of Benefit and Payment Parameters for 2019
A Final Rule by the Health and Human Services Department (Posted 4/2018)

Final Notice of Benefit and Payment Parameters for 2020
The Proposal includes payment parameters and risk adjustment, reinsurance, risk corridors; cost-sharing parameters and cost-sharing reductions; FFE user fees; open enrollment; EHB; QHP; Exchange consumer assistance programs; network adequacy; patient safety; SHOP; SADP; third-party payments to QHPs; employer definitions; fair health insurance premiums; student plans; rate review program; medical loss ratio program; eligibility and enrollment; exemptions and appeals. (Posted 2/2019).

Proposed Rule by the Health and Human Services Department (HHS)
This is a link to a fact sheet for the 2019 Notice of Benefit and Payment Parameters which highlights certain elements of the proposed rule. (Posted 11/2017)

SHOP; SADP; third-party payments to QHPs; the definitions of large employer and small employer; fair health insurance premiums; student plans; rate review program; medical loss ratio program; eligibility and enrollment; exemptions and appeals. (126 pages) (Posted 11/2017)

Proposed Rules on Use of HRAs to Pay for Individual Market Coverage
The Departments of Treasury, Labor, and Health and Human Services released long-awaited proposed regulations regarding health reimbursement arrangements (“HRA”) and other account-based group health plans.  Notably, the Proposed Regulations effectively reverse Obama-era guidance to now allow employees to use HRAs to pay for premiums for individual health insurance purchased either on or off the Exchanges. (Posted 10/2018)

Protecting Statutory Conscience Rights in Health Care; Delegations of Authority Adopted by HHS
The final rule clarifies what covered entities need to do to comply with applicable conscience provisions and requires applicants for HHS federal financial assistance to provide assurances and certifications of compliance. The rule also specifies compliance obligations for covered entities, including cooperation with OCR, maintenance of records, reporting, and non-retaliation requirements. The Rule becomes effective July 22, 2019 (Posted 06/2019).

Section 1557 (Non-Discrimination) Rule
Access to the May 13, 2016 HHS Office for Civil Rights final rule implementing Section 1557 (nondiscrimination provision based on race, color, national origin, sex, age, or disability in certain health programs or activities). Nondiscrimination protections are provided to individuals. (99 pages PDF option) (Posted 5/2016)

Short Term Medical. Limited Duration Plans Proposed
This final rule amends the definition of short-term, limited-duration insurance for purposes of its exclusion from the definition of individual health insurance coverage. This action is being taken to lengthen the maximum duration of short-term, limited-duration insurance. (Posted 8/2018)

 

General

How Premiums Are Changing In 2019
This page contains information on how premiums are changing in 2019 including an interactive map detailing changes at the county level. (Posted 12/2018)

Kaiser Family Foundation analysis of ACA-related current events
The Kaiser Family Foundation is a non-profit organization that focuses on health care issues in the United States. This website includes articles, studies and other useful resources related to Health Care reform and the ACA. (One webpage)

MLR Data and System Resources
The ACA requires health insurers to pay consumer rebates if they fail to meet the minimum allowed Medical Loss Ratio (MLR). This contains links to the MLR refunds by state, market and year.

 

Medicaid

Arkansas Medicaid Waiver
The United States District Court for the District of Columbia is vacating the approval of Arkansas’s Medicaid § 1115 waiver which included work requirements and is remanding the matter to HHS for further review. (Posted 4/2019)

Kentucky Medicaid Waiver
The United States District Court for the District of Columbia is again vacating the approval of Kentucky’s Medicaid § 1115 waiver which included work requirements and is remanding the matter to HHS for further review. (Posted 4/2019)

KFF waiver tracker

Medicaid Work Requirements Adopted in a Number of States
A number of states have submitted Medicaid Waivers with Work Requirements. (Posted 01/2016)

National Academy for State Health Policy work requirements by state

Proposed Rule:  Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction
This proposed rule would reform Medicare regulations that are identified as unnecessary, obsolete, or excessively burdensome on health care providers and suppliers. Comments were due on November 19, 2018.

2018 and 2019 Medicaid Managed Care Rate Development Guide
The 2018 and 2019 Medicaid Managed Care Rate Development Guide is for use in setting rates for rating periods for any managed care program subject to the actuarial soundness requirements in 42 CFR §438.6. CMS seeks to determine if the data, assumptions, and methodologies are consistent with Generally Accepted Actuarial Practices and Principles and if the capitation rates are appropriate. (20 pages) (Posted 5/2017)

2018 Updates to the Child and Adult Core Health Care Quality Measurement Sets This informational bulletin describes the 2018 updates to the core set of children’s health care quality measures for Medicaid and the Children’s Health Insurance Program (CHIP) (the Child Core Set) and the core set of health care quality measures for adults enrolled in Medicaid (the Adult Core Set). (Posted 12/2017)

Actuarial Standard of Practice No. 49, Medicaid Managed Care Capitation Rate Development and Certification
The link is to the final version of ASOP No. 49, Medicaid Managed Care Capitation Rate Development and Certification. (Effective 3/2015)

CMS Encounter Data Toolkit
The Centers for Medicare & Medicaid Services (CMS) The toolkit provides a guide to collecting, validating and reporting Medicaid managed care encounter data. It is a step-by-step guide for managing the daily operations involved in encounter data. The toolkit contains case studies, checklists, and links to resources that provide helpful tips and tools. (Revised 11/2013)

CMS Medicaid Policy to Combat Opioid Crisis
CMS announced a policy to allow states to design demonstration projects that increase access to treatment for opioid use disorder (OUD) and other substance use disorders (SUD). States will be able to pay for a fuller continuum of care to treat SUD, including critical treatment in residential treatment facilities that Medicaid is unable to pay for without a waiver. (Posted 11/2017)

Delivery System and Provider Payment Initiatives under Medicaid Managed Care Contracts

CMS Medicaid managed care rules include requirements for how states may implement the delivery system and provider payment initiatives under Medicaid managed care contracts, including those with managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs). (Posted 12/2017)

Early and Periodic Screening, Diagnostic, and Treatment
The link is to the Medicaid.gov website which discusses Early and Periodic Screening, Diagnostic and Treatment benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. (One webpage)  

Medicaid 101
The link is to a website run by Medicaid and CHIP Payment and Access Commission (MACPAC), a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the U.S. Department of Health and Human Services and the states on issues affecting Medicaid and the CHIP Program.(One webpage) 

Medicaid and CHIP Managed Care Final Rule
CMS released the Medicaid and CHIP Managed Care Final Rule on the Federal Register. The Rule aligns key rules with other health insurance coverage programs, modernizes how states purchase managed care for beneficiaries, and strengthens the consumer experience and key consumer protections. For questions regarding Managed care, please e-mail ManagedCareRule@cms.hhs.gov.(Technical Corrections effective 12/2016)

Medicaid Managed Care Final Rule
The final rule attempts to align Medicaid managed care with other coverages, such as Qualified Health Plans or Medicare Advantage Plans. (Posted 5/2016)

Medicaid Managed Care Marketing Regulations Frequently Asked Questions
 (Revised 1/2015) (2 pages)

Medicaid Managed Care Organizations: Considerations in Calculating Margin in Rate Setting
The Society of Actuaries Health Section Research Committee research report that describes the components of margin for calculating capitation rates in a Medicaid context along with a description of practical issues that may be encountered by MCOs. The report includes observations from interviews with MCO executives as well as financial results analysis of MCOs nationwide. (Posted 3/2017)

Medicaid State Fact Sheets
The link is to the Kaiser Family Foundation which provides Medicaid information. (Posted 6/2017) 

Medicaid.gov News Page 
The news page posts CIBs and SMDLs and other policy-related updates.

PAHP, PIHP and MCO Contracts Financial Review Documentation for At-risk Capitated Contracts Rate Setting
The link is to a checklist for Regional Offices for use in approving rates for all capitated Medicaid managed care programs. Attachment 1 includes a listing of requirements for capitated rates. (Edit Date: 7/2003)

Proposed Change to the Medicaid Managed Care Rule
CMS has posted proposed rule changes for the Medicaid Managed Care rule (also known in the Medicaid world as the “mega reg”). Comments were due by January 14, 2019 (Posted 12/2018)

State Guide to CMS Criteria for Medicaid Managed Care Contract Review and Approval
The guide covers the standards that are used by CMS to review and approve state contracts with MCOs, PIHPs, PAHPs, NEMT PAHPs, primary care case managers PCCMs and HIOs. (Revised 1/2017)

 

Medicare

Actuarial Bid Questions
CMS Office of the Actuary (OACT) hosts weekly conference calls with industry actuaries to respond to questions/issues on preparing bids for Prescription Drug and Medicare Advantage plans. OACT receives questions submitted to the "actuarial-bids" mailbox in advance of each call. The "Actuarial Bid Questions" PDF documents summarizes the responses to submitted questions. (1 web page, 11 PDF documents) (Posted 6/2016)

Approved MA and Part D Benefits Information for All Organizations that Submit a Bid
The page provides data from CMS used for bids. (Modified 10/2013)

CMS: Actuarial Bid Training – 2019   
Actuarial Bid Training provides actuaries with the program and technical guidance for preparing Medicare Advantage and Medicare Prescription Drug Bids for CY 2018. The website details training that consists of ten sessions with information that is recommended for all actuaries preparing or certifying CY 2018 bids. (1 web page) (Posted 7/2017)

CMS Landscape Files
The page provides various benefit information on Part D plans offered each year. (Posted 6/2017)

CMS: Medicare Advantage/Part D Contract Enrollment Data
The MA/PD Contract and Enrollment Data section serves as a centralized repository for publicly available data on contracts and plans, enrollment numbers, service area data and contact information for MA, PDP, cost, PACE and demonstration organizations (One webpage) (Posted 10/2016)

Information on calculating MLR for Medicare
The page provides Information on calculating MLR for Medicare. (Modified: 7/2017)

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)  
MACRA establishes the Merit-based Incentive Payment System (MIPS) to eligible clinicians or groups under a physician fee schedule and establishes incentives for participation in certain alternative payment models (APMs). (Effective date:  1/2017)  

Medicare Advantage Rates & Statistics
The capitation rate tables are posted on the CMS web site under Ratebooks and Supporting Data. The statutory component of the regional benchmarks, transitional phase-in periods for the Affordable Care Act rates, qualifying counties, and each county’s applicable percentage are also posted at this website. (1 web page) (Posted 4/2016)

Medicare Advantage and Medicare Choice Announcements and Documents
This page contains links to current and prior years’ Medicare Advantage and Medicare Choice advance notices of methodological changes, announcements issued with rates, and other special reports. (Posted 07/2017)

Proposed Rule:  Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction
This proposed rule would reform Medicare regulations that are identified as unnecessary, obsolete, or excessively burdensome on health care providers and suppliers. The comment period closed on November 19, 2018.

Medicare Data Available from Medicare Advantage (MA) bid pricing tools, submitted by MA organizations. 
Download data from Medicare Advantage (MA) bid pricing tools, submitted by MA organizations. (Updated 1/2017) 

Medicare Managed Care Manual
This manual contains guidance and payment parameters for the Medicare Advantage (MA) program. The website includes 21 chapters that are separate PDFs. (One webpage) (Posted 02/2019)

Medicare Trustees Reports
The Medicare Board of Trustees oversees the financial operations of the HI and SMI trust funds. The Social Security Act requires that the Board report annually to the Congress on the financial and actuarial status of the HI and SMI trust funds. This web page contains a menu allowing navigation to current and prior Trustees Reports. (Posted 7/2017)

Medicare.gov - Databases 
MA/PD benefit information for all current-year and prior-year plans in Access or CSV format. (One webpage) (Posted 10/2016)

Plan Payment Data
The page provides data from CMS on access to Part C Plan payment data, Part D Plan payment data and Retiree Drug Subsidy (RDS) Plan payment data by plan year. (Modified: 2/2019)

Prescription Drug Benefit Manual
This manual contains guidance and payment parameters for the Medicare Prescription Drug (PD) program. The website contains Chapters as separate PDFs from the Part D PDBM. The website editors ask that the reader check back, as they will continue to update this page as manuals are revised. (One webpage)(Modified: 3/2017)

Prescription Drug Programs
The private company website is the gateway to Medicare Advantage, Medicare Medicaid Data and Prescription Drug Programs with information about Risk Adjustment, Medicare Encounter Data, Medicare Medicaid Data and Prescription Drug Programs; including opportunities to enroll to submit data and obtain comprehensive information about data submission and reporting. The site provides valuable links to CMS instructions and other official resources. 

 

Technology

Modifications to the HIPAA Privacy Rules
The final rule on modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act (138 pages) (Posted 3/2013)

Department of Health and Human Services HIPAA Information
This page contains links to important HIPAA related information including the Security Rule, Enforcement Rule, Omnibus Rule and the Breach Notification Rule.  If also contains links to the relevant documents in the Code of Federal Regulations. (Posted 6/2017)

NAIC Insurance Data Security Model Act
The National Association of Insurance Commissioners has adopted an Insurance Data Security Model Law.  The model law creates rules for insurers, agents and other licensed entities covering data security, investigation and notification of the breach. To date, South Carolina has passed legislation to adopt the model law.  In addition, New York enacted similar regulations prior to the release of the Model by the NAIC.  No other states have enacted similar legislation thus far. (Posted 7/2018)

 

Other

Final Rules for Mental Health Parity
MHPAEA amended ERISA, the Public Health Service Act (PHS Act) and the Internal Revenue Code of 1986 requiring parity in an aggregate lifetime and annual dollar limits for mental health and medical/surgical benefits. The changes made by MHPAEA consist of new requirements, including parity for substance use disorder benefits and amendments to the existing mental health parity provisions. The changes are generally effective for plan years beginning after October 3, 2009. (58 pages) (Posted 11/2013)

The National Conference of Insurance Legislators (NCOIL)
NCOIL is a non-partisan member organization to assist state legislators to make informed decisions on insurance issues that affect their constituents and to declare opposition to federal encroachment of state authority to oversee the business of insurance. The link is to the Health, Long-Term Care & Health Retirement Issues Committee. Many documents may not be accessed without payment of a fee. (One webpage)

NAIC Model Laws, Regulations and Guidelines: Accident and Health Insurance
The NAIC is the non-partisan state trade association for state insurance regulators. Drafts of models are available at the website on the various committee, task force and working group web pages. The link is to the NAIC Publications Department. Some but not all publications are available without fee or subscription.

  • Health Actuarial Task Force
    Identify, investigate and develop solutions to actuarial problems in the health insurance industry.
  • Cancer Claims Cost Table Subgroup
    The Academy and the SOA are developing a replacement for the 1985 NAIC Cancer Claim Cost Tables as the basis for the valuation of individual cancer policies. The proposed 2016 Cancer Claim Cost Valuation Tables from the Joint American Academy of Actuaries and Society of Actuaries Cancer Claims Cost Tables Work Group is to be exposed.
  • Health Care Reform Actuarial Working Group
    Provide support for issues related to the implementation of the federal Affordable Care Act (ACA).
  • Actuarial Value Subgroup
    At the request of the federal Center for Consumer Information and Insurance Oversight (CCIIO), develop guidelines for the review of actuarial value calculations, primarily for unique benefit designs that cannot be valued using the CCIIO’s standard actuarial value calculator.
  • State Rate Review Subgroup
    Provide support for issues related to the implementation of the federal Affordable Care Act (ACA).
  • Individual Disability Valuation Table Implementation Subgroup
    Work with the Society of Actuaries (SOA) and the American Academy of Actuaries (Academy) to develop a replacement for the 1985 Commissioners Individual Disability Income Table. Ensure the Health Insurance Reserves Model Regulation (#10) remains open to accommodate the new table.
  • Medical Loss Ratio Quality Improvement Activities Subgroup
    Review new quality improvement (QI) initiatives, as reported annually on the Supplemental Health Care Exhibit Allocation Report and make recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS) on certifying for inclusion or exclusion in the QI expense category of the Supplemental Health Care Exhibit.
  • Regulatory Framework Task Force
    1) Develop NAIC model acts and regulations for state health care initiatives, and 2) consider policy issues affecting state health insurance regulation.
  • Accident and Sickness Insurance Minimum Standards Subgroup
    Review and consider revisions to the Accident and Sickness Insurance Minimum Standards Model Act (#170) and its companion regulation, the Model Regulation to Implement the Accident and Sickness Insurance Minimum Standards Model Act (#171).
  • ERISA Working Group
    Review and consider revisions to the Accident and Sickness Insurance Minimum Standards Model Act (#170) and its companion regulation, the Model Regulation to Implement the Accident and Sickness Insurance Minimum Standards Model Act (#171).
  • Model #22 Subgroup
    Review and consider revisions to the Health Carrier Prescription Drug Benefit Management Model Act (#22) related to: a) transparency, accuracy and disclosure regarding prescription drug formularies and formulary changes during a policy year; b) accessibility of prescription drug benefits using a variety of pharmacy options; and c) tiered prescription drug formularies and discriminatory benefit design.
  • Short Term Health Policies Providing Long-Term Care Benefits Subgroup
    Examine whether short-term, long-term care insurance products that are currently being discussed as part of the review and revision of the Accident and Sickness Insurance Minimum Standards Model Act (#170) and the Model Regulation to Implement the Accident and Sickness Insurance Minimum Standards Model Act (#171) should be regulated in accordance with the provisions of Model #640 and Model #641
  • Health Care Reform Regulatory Alternatives Working Group

    Provide a forum for discussion of, and guidance on, the alternatives to implementing an ACA-compliant state-based exchange and the implications of such alternatives on NAIC-member regulatory; Identify and assist NAIC members in resolving open issues that need to be addressed with regard to non-state exchange ACA alternatives; Analyze the impact of the ACA on existing NAIC-member regulatory authority, both inside and outside of a federal exchange; and Identify opportunities for NAIC members to continue to innovate and regulate outside of a federal exchange.

 

Adopted NAIC Medicaid Pass-Through Payments that are Reported as Premium
The NAIC Health Risk-Based Capital (E) Working Group has exposed a proposal the Working Group to add a new line to page XR014 and apply a 2% factor to Medicaid Pass-Through Payments that are Reported as Premium, for a 45-day comment period. (Posted 11/2017) 

Pioneer ACO new data sources available
To address the increasing number of requests for Pioneer ACO data, CMS created a standard analytical file that CMS can use to efficiently satisfy these requests. It is the intent of CMS to publish the ACO-level public-use file (PUF) that contains ACO-specific metrics as well as summarized beneficiary and provider information for performance year 1-3 of the Pioneer ACO Model. (One webpage) (Posted 4/2016)