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.
January 21, 2014
10:00 a.m. – 12:00 p.m., Pacific Time
Hospitals are required to be ICD-10 compliant on Oct 1, 2014 — less than 10 months away. Transition to the new system will be exceptionally complex. Diagnosis codes will jump from 13,000 under ICD-9 to over 68,000 with ICD-10 and procedure codes will increase from 4,000 to 87,000, respectively. This webinar will help providers understand the financial impact of ICD-10 on their organization and adequately plan for coming change.
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.
Last week, the Centers for Medicare & Medicaid Services (CMS) issued the attached rule finalizing policies from its proposed rule titled “Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards,” published June 19. The rule also finalizes eligibility and Small Business Health Options Program (SHOP) appeals provisions from the proposed rule titled “Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Procedures for Medicaid and Exchange Eligibility Appeals,” published January 22.
On Aug.15, the California Department of Health Care Services (DHCS) and the UCLA Center for Health Policy Research will conduct a conference in Sacramento to provide an overview of the Low Income Health Program (LIHP) transition and to solicit stakeholder feedback. The conference, also offered in webinar format, will be held from 9 a.m. to 4 p.m. at the Sacramento Convention Center. DHCS invites all LIHP stakeholders to participate, including those at the state, legislative, administration and county level, as well as LIHP advocates. Discussion items include the LIHP transition, including information on Covered California, Medi-Cal managed care plans, data sharing and more. Registration is free but space is limited. Visit the DHCS online registration site for more information.
Last week the U.S. Department of Health and Human Services (HHS) released its long-awaited final rule related to affordable insurance exchanges, also called health insurance marketplaces. The final rule implements specific exchange functions, including determining eligibility for and granting certificates of exemption from the individual shared responsibility payment (IRS code section 5000A).