HHS/Treasury Issue Proposed Rules on Health Insurance Exchanges

On August 12th the Treasury and HHS issued proposed regulations on how PPACA health insurance exchanges are to determine the eligibility of uninsured individuals and employees of small businesses for “affordability” tax credits through a simplified, coordinated system that verifies income and eligibility in “real time” from federal data sources.  The proposed rules also provide procedures for the Small Business Health Options Program (SHOP) that allows employees of qualified small businesses to buy health insurance on either state exchanges or a separate exchange.  The HHS rule defines how an individual may receive advance payments of tax credits if a state exchange determines that the individual is expected to have a household income of at least 100-400% of the Federal Poverty Level (FLP) in the current tax year.  About 16 million previously uninsured are expected to qualify for Medicaid due to earnings of less than 133% of the FPL.  To enforce the employer mandate to offer coverage for businesses employing more than an average of 50 full-time workers, an IRS rule requires such employers to report the value of their health care plans or pay a tax penalty of up to $3,000 per employee/per year, if they fail to offer affordable coverage.  In related news, HHS announced that thirteen states and DC have been awarded $185 million in grants to fund efforts in developing health insurance exchanges.  HHS also announced that more than $28 million in PPACA authorized grants will be made to help develop and expand community health centers across the nation.

Question of Constitutionality of Individual Mandate Headed to Supreme Court?

A second circuit court, the U.S. Court of Appeals for the Eleventh Circuit, has issued an opinion on the constitutionality of the PPACA individual mandate.  In a 2-1 ruling, the court held that Congress exceeded its powers under the Constitution’s commerce clause in enacting the individual mandate, but did not strike down the remainder of the law as ruled by the district court and argued by the state of Florida and other state plaintiffs.  In ruling that the individual mandate was “severable” from the other parts of the PPACA, the circuit court said that the proper test was whether Congress would have enacted the PPACA without the individual mandate.  The first court to rule on the issue, the Court of Appeals for the Sixth Circuit, held the opposite in that the mandate meets constitutional muster.  The Thomas More Law Center, the plaintiff in the latter action, has filed a petition for review with the Supreme Court.  The split decision in the two circuits would appear to guarantee that the Supreme Court will take up the issue, the only question being the timing, probably in the next session with a decision possibly being issued during next year’s election season.

Proposed Quality Measures for Medicaid

A subcommittee of the AHRQ National Advisory Council approved a draft of 24 health quality measures for Medicaid-eligible adults which CMS will use to compare quality of care among state Medicaid programs.  The measures focus on five areas: prevention and health promotion; management of acute conditions; management of chronic conditions; family experiences of care; and availability of services.

New DEMO for Psychiatric Emergencies

CMS announced a $75 million 3-year demonstration program that will allow states to receive federal matching dollars when Medicaid patients with psychiatric emergencies are treated in private inpatient facilities with 17 or more beds.  The goal is to remove such patients from emergency room care.

Proposed Medicare Coverage of Certain Counseling Benefits

CMS issued a proposed Medicare coverage decision under which high intensity behavioral counseling and screening would be covered in the case of STIs (sexually transmitted infections) and cardiovascular disease.

Grants for Physician Quality DEMOs

CMS announced that four physician groups--in WI, MN, MO, and MI--have been awarded $29.4 million for the fifth and final year of a Medicare quality incentive demonstration project as a result of the PGP’s health quality improvements and savings they have achieved for the Medicare program.

Recently Introduced Health Legislation

H.R. 2798 (ALZHEIMER’S DISEASE), to amend the Public Health Service Act to authorize grants for training and support services for Alzheimer’s patients and their families; WATERS; to the Committee on Energy and Commerce, Aug. 5.

H.R. 2799 (DIABETES), to amend the Public Health Service Act to authorize grants to provide treatment for diabetes in minority communities; WATERS; to the Committee on Energy and Commerce, Aug. 5.

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