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CMS issues proposed rule on ACA insurance-related provisions, PSOs

November 26, 2013

The Centers for Medicare & Medicaid Services yesterday released a proposed rule detailing payment parameters and oversight provisions related to changes in the insurance elements of the Patient Protection and Affordable Care Act. These include proposed 2015 rates and fees, risk mitigation programs, individual and small employer Marketplace requirements, student health insurance coverage, health plan audits and a variety of technical provisions. Of particular interest to hospitals is the proposed rate of $44 per capita for 2015 contributions to the reinsurance pool intended to protect plans in the individual marketplaces. This is down from the $63 rate scheduled for 2014. Another provision is a controversial White House proposed exemption of certain self-funded health plans (thought to be mostly union-sponsored Taft-Hartley plans) from having to contribute to the reinsurance pool in 2015 and 2016. Many hospitals are self-funded and must contribute to the reinsurance pools along with those that have fully insured plans. It appears that self-funded plans, including hospitals, that use third-party administrators or insurance issuers for claims processing and adjudication or enrollment would not be exempted from making the reinsurance contributions. In addition, the rule discussed a provision related to whether hospitals of more than 50 beds must have an agreement with a Patient Safety Organization in order to contract with qualified health plans. CMS proposes that, for now, hospitals will not need to contract with a PSO. AHA members received a Special Bulletin today with more information on this issue. Comments on the proposed rule are due Dec. 26.