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.
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
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.
final rule also:
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.
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.
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).
policies in this rule:
proposed rule seeks to amend
existing regulations to implement the SHOP effective January 1, 2015.
interim final regulation
will adjust risk corridors
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
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
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.
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.
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