The Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Internal Revenue Service (IRS) have issued rules and requests for information on several provisions of the health reform law, which are listed below. Families USA has submitted comments on many of these provisions. For information on other provisions, visit the regulations page of HealthCare.gov.
Accountable Care Organizations (ACOs)
Basic Health
Benchmark Plans in Medicaid
Charitable Hospital Care (Updated 9/12)
CHIPRA Outreach and Enrollment Grants
Coverage for Young Adults Up to Age 26
Essential Health Benefits
Grandfathered Plans
Health Information Technology (HIT)
Health Insurance Exchanges (Updated 11/12)
Innovation Waivers
Long-Term Services and Supports
Medicaid 90/10 Match for Eligibility Systems
Medicaid Expansion, Eligibility, and Enrollment
Medical Loss Ratio Requirements
Medicare Part C and Part D
Patients' Bill of Rights
Pre-Existing Condition Insurance Plan
Preventive Services and Value-Based Insurance Design
Rate Review of Health Insurance Premiums
Reinsurance for Early Retirees
Right to Appeal Health Plan Decisions
Section 1115 Medicaid and CHIP Demonstrations
Small Business Tax Credits
Summary of Benefits and Coverage (SBC)
Website for Coverage Options
Accountable Care Organizations (ACOs)
Basic Health
The Affordable Care Act provides an option for states, called the Basic Health program, that allows states to create a separate program with federal funding for people who are not eligible for Medicaid and who earn up to 200 percent of poverty. States that take up this option will receive federal funding that is equal to 95 percent of the value of the premium credits and the cost-sharing subsidies that eligible people would have received in the exchange. In August 2011, CMS issued a Request for Information (RFI) on the Basic Health program seeking input from stakeholders to aid in the development of future regulations and guidance.
Benchmark Plans in Medicaid
Health reform made changes to the requirements for Medicaid state plans that provide benchmark-equivalent coverage. Benchmark plans will be required to cover mental health services, prescription drug coverage, and family planning services (for women of childbearing age who want such services). CMS has released guidance on the implementation of two Medicaid benefits-related provisions under health reform: new rules for benchmark plans and the family planning services option. The family planning provisions went into effect on March 23, 2010, and the benchmark benefits final rule went into effect on July 1, 2010.
Charitable Hospital Care
On June 26, the Internal Revenue Service issued proposed rules for nonprofit hospitals to provide discounts and charity care under a hospital financial assistance program.
CHIPRA Outreach and Enrollment Grants
The Affordable Care Act includes an additional $40 million for outreach and enrollment grants under the CHIP Reauthorization Act (CHIPRA). On February 3, 2011, CMS released a funding opportunity announcement for a second round of CHIPRA outreach and enrollment grants to states, local governments, community-based and nonprofit organizations, Indian tribes, and others to support outreach activities and enrollment of children who are eligible for Medicaid or CHIP. Grant applications were due by April 18, 2011, and awards were announced in July 2011.
Coverage for Young Adults Up to Age 26
Under health reform, young adults can stay on their parents' health plans until they turn 26. The IRS, DOL, and HHS have released an interim final rule for this provision. Public comments for this rule were due by August 11, 2010.
Essential Health Benefits
In 2014, health plans sold through an exchange will have to cover "essential health benefits." The law lists a number of categories of benefits that will have to be covered, but the scope of that coverage will be determined by HHS based on a survey of typical job-based plans. The Institute of Medicine made recommendations to the Secretary of HHS about the criteria and methods used for determining and updating the essential benefits package.
Grandfathered Plans
Health plans that were in place on the day that the health reform law was enacted are considered "grandfathered" and do not have to comply with all provisions of the law. The Departments of Health and Human Services, Treasury, and Labor released an interim final rule on grandfathered status for health plans. Public comments on this rule were due by August 16, 2010. On November 15, 2010, the Departments released an amendment to this interim final rule that changes the definition of grandfathered group plans. Comments on this amendment were due by December 17, 2010.
Health Information Technology (HIT)
Health Insurance Exchanges
The Affordable Care Act requires the establishment of exchanges, which are regulated marketplaces where eligible consumers will be able to buy health insurance.
- In August 2012, HHS issued an amendment to the Interim Final Rules for the Pre-Existing Condition Insurance Plan (PCIP) program that changed the definition of "lawfully present" to exclude individuals granted deferred action under the Deferred Action for Childhood Arrivals (DACA) policy. This definition change affects eligibility for the PCIP program, premium tax credits, and exchange coverage.
- In June 2012, HHS released a Request for Domains, Instruments, and Measures for Development of a Standardized Instrument for Use in Public Reporting of Enrollee Satisfaction with their Qualified Health Plan and Exchange.
- In May 2012, HHS released the Draft Blueprint for Approval of Affordable State-Based and State Partnership Insurance Exchanges.
- In May 2012, HHS released General Guidance on Federally Facilitated Exchanges.
- In March 2012, HHS released the final rule on Exchange and QHP Establishment.
- In December 2011, HHS released a draft version of the state exchange certification application.
- In August 2011, HHS released a rule pertaining specifically to exchange eligibility for individuals and small businesses.
- In August 2011, the Treasury and IRS released a proposed rule regarding premium tax credits for exchange coverage.
- In July 2011, HHS issued a proposed rule on the Establishment of Exchanges and Qualified Health Plans.
- In 2010, HHS issued a request for comments to aid in the development of standards for the establishment and operation of the exchanges, to address other exchange-related provisions in the Affordable Care Act, and to inform the process of awarding grants to assist states in planning and developing their exchanges.
- Comments from Families USA on the Amendment Regarding Deferred Action for Childhood Arrivals (DACA) Policy (Submitted October 26, 2012)
- Comments from Families USA on the IRS Final Premium Tax Credit Rule (Submitted August 21, 2012)
- Comments from Families USA on the HHS Request for Domains, Instruments, and Measures for Development of a Standardized Instrument for Use in Public Reporting of Enrollee Satisfaction with their Qualified Health Plan and Exchange (Submitted June 29, 2012)
- Comments from Families USA on the Draft Blueprint for Approval of Affordable State-Based and State Partnership Insurance Exchanges (Submitted June 18, 2012)
- Comments from Families USA on the General Guidance on Federally Facilitated Exchanges (Submitted June 18, 2012)
- Comments from Families USA on the HHS Final Rule for Exchange and QHP Establishment (Submitted on May 11, 2012)
- Comments from Families USA on the draft state exchange certification application (Submitted on January 9, 2012)
- Comments from Families USA on the HHS Proposed Rule for Exchange and QHP Establishment (Submitted on October 31, 2011)
- Comments from Families USA on the HHS Proposed Exchange Eligibility Rule (Submitted on October 31, 2011)
- Comments from Families USA on the IRS Proposed Premium Tax Credit Rule (Submitted on October 31, 2011)
- Comments from Families USA on the NAIC White Paper "Health Insurance Exchanges under the Affordable Care Act: Governance Options and Issues" (Submitted on May 16, 2011)
- Comments from Families USA on the NAIC Exchanges Model Act (Submitted on November 8, 2010)
- Comments from Families USA in Response to HHS's Request for Comments (Submitted on October 1, 2010)
Innovation Waivers
Section 1332 of the Affordable Care Act allows states to request "innovation waivers" beginning in 2017 to pursue their own strategies for health coverage expansions. States could ask to waive any of the following sections of the law: provision of exchanges, cost-sharing and premium assistance, the responsibility of employers to provide coverage, and the responsibility of individuals to maintain coverage. Proposed rules for state applications and a public input process are available online. Comments were due by May 13, 2011. To receive a waiver, states must demonstrate that the state's innovation meets the following criteria:
- Provides coverage that is at least as comprehensive as the coverage offered through health insurance exchanges
- Makes coverage at least as affordable as it would be through the exchanges
- Provides coverage to at least as many residents as otherwise would have been covered under the Affordable Care Act
- Does not increase the federal deficit
Long-Term Services and Supports
On April 27, 2012, CMS released the final rule for the Community First Choice (CFC) option. Under the final rule, states must meet several specific requirements, including establishing and maintaining a quality assurance system for CFC services; and meeting or exceeding the state's current level of expenditures for home- and community-based attendant services for the first 12 months of the program. States are also required to use a person-centered service plan that is based on an assessment of functional need and that allows for services to be self-directed. The final rule clarifies that people should be determined to need an institutional level of care to be eligible for CFC services.
On April 27, 2012, CMS released proposed rules for the Home and Community-Based Services 1915(i) State Plan Benefit, which was originally authorized in 2005 and later improved by the Affordable Care Act to make it easier for states to provide Medicaid coverage for home- and community-based services (HCBS). These new rules allow states to offer and receive federal reimbursement for HCBS as part of the regular state Medicaid benefit without the use of a waiver so they can provide a full array of services and supports to people who do not qualify for an institutional level of care but who have significant service needs. The rule also proposes a definition of "home- and community-based" settings that will serve as a common definition for services offered through the Community First Choice option and the Section 1915(i) State Plan Benefit. Comments on the proposed rule are due on July 2.
On October 19, 2011, CMS released an Implementation Guide for the Affordable Care Act's Balancing Incentive Program. The guide provides more information on structural changes and other requirements to help states with applications and augments the State Medicaid Director Letter and program application that were issued on September 12, 2011.
On September 12, 2011, CMS issued a State Medicaid Director Letter providing guidance to states on the implementation of the State Balancing Incentive Payments Program (Section 10202 of the Affordable Care Act) and the final grant application for the program. Effective October 1, 2011, this program offers a targeted increase in federal matching payments (FMAP) for home- and community-based or non-institutional long-term services and supports (LTSS). The enhanced matching payments are tied to the percentage of a state's non-institutional LTSS, with higher FMAP increases going to states that require reforms to achieve allocating 50 percent or more of spending toward home- and community-based care. Total funding over the four-year period (October 1, 2011-September 30, 2015) cannot exceed $3 billion in federal increased matching payments.
On July 12, 2011, CMS released the proposed rule for Face-to-Face Requirements for Home Health Services; Policy Changes and Clarifications Related to Home Health. The proposed rule would revise the definition of home health services to include all individuals who need assistance with activities of daily living (ADLs), not just those who are homebound, and would not restrict services to only those provided in the home, but would include coverage for other forms of individual assistance that promote independent living as well. The proposed rule also explains new requirements for providers for authorizing the provision of health home services.
On April 15, 2011, CMS released a proposed regulation that provides states the flexibility to serve multiple population groups (seniors or people with disabilities, people with developmental disabilities, and individuals with mental illness) in a single home- and community-based services waiver. Under current rules, states must serve one target group per waiver. The proposed rule also clarifies the required characteristics of a home- and community-based setting and sets out new requirements for person-centered care plans.
The Affordable Care Act includes $3.7 billion in new federal funds to provide personal attendant services and supports in Medicaid through the Community First Choice program. On February 22, 2011, HHS released the proposed rule for the Community First Choice program, which describes the details of the program and solicits public comments, which were due on April 26, 2011. Starting in October 2011, the Community First Choice option allows states to receive a 6 percent increase in federal matching funds for providing community-based attendant services and supports that help individuals in Medicaid with activities of daily living (such as bathing, eating, and health-related tasks) through hands-on assistance or supervision. States may also cover costs that are related to moving individuals from an institution to the community. To qualify for the increased federal funds, states must develop person-centered plans that allow individuals to determine how services are provided to achieve or maintain their independence. States must also establish implementation councils with a majority membership consisting of people with disabilities, elderly individuals, and their representatives to advise in the design and implementation of the Community First Choice option.
On November 16, 2010, CMS released its State Medicaid Director Letter on the Health Homes provision in the Affordable Care Act. The letter provides guidance on the implementation of the state option to create Health Homes for people with chronic conditions. The option gives states the opportunity to receive additional federal support for enhancing the integration and coordination of primary, acute, behavioral, and long-term services and supports for people of all ages with chronic illness.
Medicaid 90/10 Match for Eligibility Systems
In November 2010, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that will allow states to draw a 90 percent federal matching rate for the development and maintenance of Medicaid eligibility systems. States must meet a set of federal performance standards and conditions that are intended to effectively and efficiently streamline, simplify, and modernize the enrollment processes. Once the rule is finalized, this 90 percent match will be available to states until December 31, 2015. States that qualify for this enhanced funding will also receive a 75 percent federal match for maintaining these systems in 2016 and beyond.
Medicaid Expansion, Eligibility, and Enrollment
The Affordable Care Act requires states to expand Medicaid coverage to non-elderly people with incomes less than 133 percent of the federal poverty level ($24,645 for a family of three in 2011) by January 1, 2014. However, it allows states to phase in this expansion beginning on April 1, 2010, through the state plan amendment process. This letter to state health officials and state Medicaid directors provides guidance to states that want to pursue this early expansion option.
In order to seamlessly enroll millions of Americans in affordable coverage, the federal government and states will need to implement new eligibility and enrollment systems and policies. In August 2011, CMS released a proposed rule pertaining to Medicaid eligibility and enrollment. Comments on the proposed rule were due by October 31, 2011. In March 2012, CMS released a final rule in which some sections were issued as interim final. Comments on the provisions issued as interim final were due by May 7, 2012.
Medical Loss Ratio Requirements
Under health reform, insurance plans will be required to spend a set share of premium dollars on providing care and improving health care quality (as opposed to administration, marketing, and profits). The IRS, DOL, and HHS released a request for information regarding how to implement these requirements in April 2010. On December 1, 2010, these agencies released an interim final rule to implement the MLR requirements, and a technical correction to that rule was released on December 30, 2010. Comments on the interim final rule with corrections were due by January 31, 2010.
Medicare Part C and Part D
In November 2010, the Centers for Medicare and Medicaid Services (CMS) issued proposed regulations for the Medicare Part C and Part D programs that implement provisions of the Affordable Care Act and make other changes to the two programs. Families USA joined with other advocates to provide comments on the regulations.
Under health reform, the Medicare Part D coverage gap (or "doughnut hole") will be gradually closed. Starting in 2011, beneficiaries will receive a 50 percent discount on brand-name drugs. CMS released initial draft guidance on how the discount program will work in April 2010. CMS issued final guidance on how the program will work on May 21, 2010.
Patients' Bill of Rights
Interim final rules were published in the Federal Register on June 28, 2010, to implement a number of patient protections. The rules do the following:
Pre-Existing Condition Insurance Plan
The Affordable Care Act requires the creation of temporary high-risk pools or Pre-Existing Condition Insurance Plans to provide affordable coverage until the exchanges are up and running in 2014 for uninsured people with a pre-existing condition. The interim final rules focus on the administration of the program, eligibility and enrollment, benefits, premiums, funding, and appeals and oversight rules. Public comments were due by September 28, 2010.
Preventive Services and Value-Based Insurance Design
Under the Affordable Care Act, new plans in the group health and individual markets to provide full coverage of recommended preventive services. This means that beneficiaries will not have any cost-sharing for these services. The regulations implementing this provision and the list of recommended preventive services are available online.
The law also authorizes the HHS Secretary to issue guidelines to permit these plans to use value-based insurance design in the coverage of the recommended preventive services. Value-based insurance design uses incentives to encourage beneficiaries to use high-value health care services or providers. On December 28, 2010, the Departments of HHS, Labor, and Treasury issued a request for information related to the development of the guidelines for value-based insurance design for the coverage of these services. Public comments were due by February 28, 2011.
Rate Review of Health Insurance Premiums
Under health reform, the Secretary of HHS will work with the states to establish a process for annual review of "unreasonable" premium increases that are requested by insurance companies. HHS released a request for information on this process in April 2010. On December 23, 2010, HHS released a proposed rule to implement the rate review provisions of the Affordable Care Act. HHS issued a final rule on May 23, 2011, but left open for comment a question about whether association health plans should be subject to rate review. This was clarified in a final rule on September 1, 2011.
Reinsurance for Early Retirees
The health reform law created a reinsurance program to help employers afford to provide coverage for early retirees. Employers must submit a grant application to participate in the program. HHS has issued an interim final rule on this provision. Public comments for this rule were due by June 4, 2010.
Right to Appeal Health Plan Decisions
Health reform strengthens consumers’ right to appeal denials of coverage, both within a plan and to an external reviewer. Interim final rules on this new right were added to the Federal Register with a request for comment. The regulations will generally affect group and individual health insurance plans that are not grandfathered. The regulations provide plans and issuers with guidance necessary to comply with the law. Public comments were due by September 21, 2010. The Department of Labor subsequently posted public comments, transitional guidance, model notices, and a request for information on a federal appeals system.
Section 1115 Medicaid and CHIP Demonstrations
On February 22, 2012, CMS issued the final rule to implement the proposed regulation for Section 1115 Medicaid and CHIP waiver demonstration projects. The rule requires state and federal governments to provide the public with notice and information about proposed and approved demonstration projects, as well as a 30-day comment period during the application and approval process, for waiver proposals and for extensions of existing demonstrations. States must also show how they have considered public comments in their final demonstration project applications. As part of the public comment process, states are required to hold at least two public hearings, and they must hold a public forum six months after a waiver is implemented to evaluate how the waiver is operating.
Also on February 22, 2012, CMS issued requirements regarding transparency and public input for the State Innovation Waivers that were created by the Affordable Care Act.
In September 2010, the Centers for Medicare and Medicaid Services (CMS) issued a proposed regulation implementing new transparency and public notice procedures for Section 1115 Medicaid and CHIP waivers. These regulations were required under the Affordable Care Act. They establish a more robust public notice, review, and approval process for Section 1115 Medicaid and CHIP demonstrations.
Small Business Tax Credits
Starting with the 2010 tax year, many small businesses can qualify for a new tax credit that can help them afford to cover their workers. Information about the credit is available on the IRS website.
Summary of Benefits and Coverage (SBC)
The Affordable Care Act (section 2715) requires all private insurance group, self-insured, and individual health plans to provide a Summary of Benefits and Coverage (SBC) and a Uniform Glossary of Medical and Insurance Terms (Glossary) to all enrollees and those shopping for health insurance. Together, the SBC and Glossary will help consumers and employers compare health insurance products before they select a plan, as well as clearly explain the terms of coverage, exceptions to coverage, and plan changes in a standard format and plain language that is easy to understand for the average consumer.
Website for Coverage Options
Consumers in all states can identify their options for insurance coverage on a website developed by HHS. HealthCare.gov provides information on several options, including private insurance, Medicaid, CHIP (the Children's Health Insurance Program), and high-risk pools. HHS has issued an interim final rule for the portal. Public comments were due by June 4, 2010.
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