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  • OPM Final Rule Clarifies That Multi-State Plans Must Offer EHBs

    On Friday, the US Office of Personnel Management (OPM) published a final rule establishing standards for the Multi-State Plan Program (MSPP) to promote competition in the new health insurance marketplace, also known as the "exchanges," and  ensure that consumers have more high-quality, affordable insurance choices.  

    Under the MSPP, OPM will enter into contracts with private health insurance issuers to provide at least 2 Multi-State Plans (MSPs) in each state's exchange. MSPs will be established in at least 31 exchanges this year, with coverage to be extended to the exchanges/marketplaces in every state and the District of Columbia by 2017. At least 1 of these issuers must be a nonprofit entity. All state and federal laws that apply to Qualified Health Plans (QHPs) also will apply to MSPs. 

    Important to physical therapists is the rule's clarification that MSPs must offer essential health benefits (EHBs), and MSPP issuers must comply with state standards relating to substitution of state benchmark benefits or standard benefit designs. As reported in News Now on February 21, a final rule on EHBs gives states authority to impose more stringent requirements on EHBs substitution than the federal regulation, meaning that states can prohibit substitution within EHB categories altogether. Additionally, MSPP plan issuers are directed to follow state definitions of habilitative services and devices where they exist. If a state has not defined the benefits, OPM will determine them during negotiations with the MSPP issuer. To ensure network adequacy (adequate number of provider and facility types),  the rule adopts an approach in which the MSPP will establish a uniform standard for network adequacy using time and distance standards similar to the Centers for Medicare and Medicaid Services' standards for Medicare Advantage plans and Medicare Part D.

    The final rule also:

    • Reflects OPM's commitment to collaborate with states to ensure that the MSPs are competitively neutral in the marketplaces.
    • Sets standards related to how OPM will coordinate with states and HHS to approve rates, standards for rating, medical loss ratios, and an MSPP issuer's participation in reinsurance, risk adjustment, and risk corridor programs.
    • Establishes how OPM will monitor contract performance for the MSPP, including ensuring quality assurance, preventing fraud and abuse, and possible contract compliance actions.
    • Creates a process and standards for handling appeals for enrollees that are denied claims for payment or service.

    The initial open enrollment period for MSPs, as with QHPs, begins October 1 for coverage beginning January 1, 2014. Individuals and small businesses wishing to enroll in MSPs will then be able to enroll through the marketplace in their state. However, an MSP may not be available in every state until 2017.

    Rules Aim to Implement Standards to Ensure Quality Insurance Choices for Americans

    In addition to the Multi-State Plan Program final rule issued Friday, the federal government released other rules implementing portions of the Affordable Care Act to encourage cost-sharing, stabilize health insurance premiums, and prevent providers from denying coverage. 

    The Notice of Benefit and Payment Parameters final rule expands upon the standards set forth in earlier rules and provides further information on the permanent risk adjustment, transitional reinsurance and temporary risk corridors programs, advance payments of the premium tax credit, cost-sharing reductions, medical loss ratio, and the Small Business Health Options Program (SHOP).

    Key policies in this rule:

    • Reduce the incentives for health insurance issuers to avoid enrolling people with preexisting conditions.
    • Stabilize premiums in the individual market for health insurance.
    • Protect health insurance issuers against uncertainty in setting premium rates.
    • Help working Americans afford health insurance in the Exchanges.
    • Finalize a number of provisions to provide qualified health plan (QHP) options for the SHOP.
    • Amend the Medical Loss Ratio program, also known as the 80/20 rule.

    A proposed rule seeks to amend existing regulations to implement the SHOP effective January 1, 2015.

    An interim final regulation will adjust risk corridors calculations that would align the calculations with the single risk pool provision. It also sets standards permitting issuers of QHPs the option of using an alternate methodology for calculating the value of cost-sharing reductions provided for the purpose of reconciliation of advance payments of cost-sharing reductions.

    CMS Revises Home Health Therapy Q&As to Address Issues With Functional Reassessments

    The Centers for Medicare and Medicaid Services (CMS) recently updated its therapy question-and-answer document that clarifies several provisions regarding the therapy functional reassessment requirement under the Medicare Home Health Part A benefit. Medicare pays only for visits in which the therapy reassessment is done in compliance with the Medicare regulations. Noncovered therapy visits are not to be included in the counting of therapy visits for the purpose of determining when certain required therapy reassessment visits need to occur.

    In the Q&A, CMS clarifies that home health agencies and therapists should not change the number of therapy visits a patient receives based on whether prior visits were covered by Medicare, and patients should receive only the number of therapy visits delineated in the plan of care. The Q&A also provides detailed examples of when the therapy reassessment is missed or is not compliant and its subsequent effect on the counting of Medicare-covered therapy visits in single and multiple therapy cases.

    CMS requires that the patient's function must be initially assessed and periodically reassessed by a qualified therapist of the corresponding discipline for the type of therapy being provided (ie, physical therapy, occupational therapy, or speech-language pathology services). When more than 1 therapy discipline is being provided, the corresponding qualified therapist would perform the reassessment during the regularly scheduled visit associated with that discipline that is scheduled to occur closest to the 13th and 19th visit, but no later than the 13th and 19th visit.