21. November 2012 · Comments Off · Categories: Health Law, Health Trends

Yesterday, November 20, the bell rang.  CMS issued its proposed rule on insurance exchanges and their requirements.  CMS essentially has reaffirmed what the ACA requires.  This is not unexpected, but it demonstrates how the “sturm and drang” of the dialogue pre-2012 election has now officially been replaced with a certain normality as the proposed rules are released, reviewed, and then made final.  Don’t expect these proposed rules to change much.

The quick take-aways are:

  • Whether state or federally run, or a mix, the all-important insurance exchanges will not be able to deny coverage and will not be able to charge certain types of patients (women, people with pre-existing conditions) more for coverage.  Remember – CMS just gave the states an additional four (4) weeks to consider to what extent they wish to have the federal government involved in running their individual state exchanges.
  • One of the “quid pro quos” of the ACA – that as the number of covered lives is increased, other types of payments to hospitals for caring for the uninsured (e.g. the DSH payments) fade away over time – remains unchanged and is now on track.
  • In the exchanges, insurers will have to cover 10 “basic” health care benefits – such as ER care, maternity care, prescriptions, and hospital stays.

It will be interesting to see in what direction states that have not yet made a choice as to their exchange model choose to go.



23. August 2012 · Comments Off · Categories: Health Law · Tags:

In its OPPS rule for 2013, CMS has asked for comments from hospitals as to whether there would be greater clarity “regarding patient status if there were more specific criteria for patient status in terms of how many hours a patient remains in a hosptial.”  In other words, would a “bright-line” test of, say, 24 hours determine whether someone is an inpatient under all circumstances? 

Clearly, the Recovery Auditors target “inpatient cases” becasue denials of inpatient status result in income for RACs. 

It is possible that a bright line test would result in a change of emphasis from review of the setting to review of the appropriatness of medical necessity.  Stay tuned – but comments are due September 4.

H.B. 1297 says that its purpose is to “preserve the state’s status as the prmary regulator of the business of insurance within New Hampshire,” and that no NH state agency shall plan, create or enable a state-based exchange for health insurance under the Affordable Care (health reform) Act.  At the same time, however, the new law does allow state officials, the NH DOI, to interact with the federal government concerning the creation of a federally facilitied exchange for New Hampshire. 

We will see how this turns out, because the Commissioner of the Department of Insurance still has authority to regulate all insurance products sold in the state.