The Managed Care Committee is responsible for policy development on matters that affect the environment between health plans and hospitals. The Committee reviews and provides policy recommendations on legislation and regulations regarding managed care and reimbursement. The Managed Care Committee also participates in developing advocacy priorities with the Legislature and regulatory agencies like the Department of Managed Health Care and the Department of Insurance.
For more information, contact Dietmar Grellmann, senior vice president, managed care & professional services, at (916) 552-7572.
CHA and other hospital organizations testified yesterday at a hearing held by the Department of Insurance to review possible revisions to its network adequacy regulations. The Department plans to revise its regulations to respond to changes in health coverage resulting from the Affordable Care Act and related state legislation. CHA, along with Private Essential Access Community Hospitals and the California Children’s Hospital Association, testified about the impact of network changes on hospitals. CHA focused its comments on the trend toward narrow networks and the impact on rural hospitals, academic medical centers, children’s hospitals and behavioral health providers.
Insurance Commissioner Dave Jones, who chaired the hearing, noted testimony from several participants regarding the need to ensure that the physicians and specialists who refer and practice in network hospitals are also in the network – otherwise the coverage is illusory. CHA also highlighted the importance of provider networks including the full spectrum of post-acute care services. CHA’s comments are attached.
Yesterday, the U.S. Department of Health and Human Services (HHS) issued guidance regarding whether qualified health plans (QHPs) are considered federal health care programs under section 1128B of the Social Security Act. HHS concluded that it does not consider QHPs, other programs related to the federally facilitated marketplace, and programs under Title I of the Affordable Care Act to be federal health care programs.
Because the federal anti-kickback statute only applies to federal health care programs, it will not apply to qualified health plans and, as a result, will not be a barrier for hospitals or health systems that wish to subsidize premiums for health plans purchased on the exchanges for individuals in need of assistance. However, California providers may still face risks under state law if they offer premium assistance programs. It is possible that this risk may be addressed by participating in a properly structured foundation; hospitals should seek the advice of counsel. The rules are more clear when applied to a Certified Enrollment Entity (CEE) and Certified Enrollment Counselor (CEC). Recent regulations adopted by Covered California prohibit a CEE or CEC from paying any part of the premium to or on behalf of an enrollee. These regulations would apply to a hospital that is a CEE.
The U.S. Department of Health & Human Services (HHS) has released guidance regarding the penalty dates related to the individual shared responsibility provision under the Affordable Care Act (ACA). The length of the initial open enrollment period and the coverage effective dates, in tandem with the terms of the short coverage gap exemption, inadvertently created the possibility that an individual who enrolled in coverage through a marketplace (exchange) during an initial open enrollment period could be liable for a shared responsibility payment for months prior to the effective date of that coverage, if the individual was not otherwise exempt. According to the new guidance, HHS recognizes that the duration of the initial open enrollment period implies that individuals have until the end of the initial open enrollment period to enroll in coverage through a marketplace while avoiding liability for the shared responsibility payment.