Final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act) related to the Small Business Health Options Program (SHOP)

Summary This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act) related to the Small Business Health Options Program (SHOP). Specifically, this final rule amends existing regulations regarding triggering events and special enrollment periods for qualified employees and their dependents and implements a transitional policy regarding employees' choice of qualified health plans (QHPs) in the SHOP. Dates These regulations are effective on July 1, 2013. For Further Information Contact Leigha Basini at (301) 492-4307. Supplementary Information I. Executive Summary Beginning in 2014, individuals and small businesses will be able to purchase private health insurance through competitive marketplaces, called Affordable Insurance Exchanges or “Exchanges” (also called Health Insurance Marketplaces). Section 1311(b)(1)(B) of the Affordable Care Act contemplates that in each State there will be a SHOP that assists qualified employers in providing health insurance options for their employees. The final rule, Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers (Exchange Establishment Rule), (1) as modified by the Notice of Benefit and Payment Parameters for 2014, (2) sets forth standards for the administration of SHOP Exchanges. In this rule, we finalize provisions proposed in the Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program Notice of Proposed Rule Making, (3) which amends some of the standards established in the Exchange Establishment Rule. In the Exchange Establishment Rule, we established standards for special enrollment periods for people enrolled through an individual market Exchange, and provided that, in most instances, a special enrollment period is 60 days from the date of the triggering event. See 45 CFR 155.420. We also made these provisions applicable to SHOPs, at § 155.725(a)(3). In the proposed rule we proposed and this final rule amends, the special enrollment period for the SHOP to 30 days for most applicable triggering events, so that it aligns with the special enrollment periods for the group market established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (4) To further align the SHOP provisions with HIPAA, we also proposed that if an employee or dependent becomes eligible for premium assistance under Medicaid or the Children's Health Insurance Program (CHIP) or loses eligibility for Medicaid or CHIP, this would be a triggering event, and the employee or dependent would have a 60-day special enrollment period to select a QHP. This triggering event had previously been inadvertently omitted from the regulations because it applies only to group health plans and health insurance coverage in the group market. We also proposed to make a conforming change to § 156.285(b)(2), so that this section references the SHOP special enrollment periods in a way that is consistent with our proposed changes to § 155.725. In the Exchange Establishment Rule, we also set forth the minimum functions of a SHOP, including that the SHOP must allow employers the option to offer employees all QHPs at a level of coverage chosen by the employer, and that the SHOP may allow employers to offer one or more QHPs to qualified employees by other methods. We proposed and are now finalizing the following transitional policy. For plan years beginning on or after January 1, 2014 and before January 1, 2015, a SHOP will not be required to permit qualified employers to offer their qualified employees a choice of QHPs at a single level of coverage, but will have the option of doing so. Federally-facilitated SHOPs (FF-SHOPs) will not exercise this option, but will instead allow employers to choose a single QHP from the choices available in FF-SHOP to offer their qualified employees. This transitional policy is intended to provide additional time to prepare for an employee choice model and to increase the stability of the small group market while providing small groups with the benefits of SHOP in 2014 (such as a choice among competing QHPs and access for qualifying small employers to the small business health care tax credit). We also proposed changes to the effective date of the SHOP premium aggregation function set forth at § 155.705(b)(4) in the Exchange Establishment Rule consistent with this transitional policy, which we are finalizing in this rule. For the reasons set forth in the preamble, the Department of Health and Human Services amends 45 CFR parts 155 and 156 as set forth below: Regulatory Text Part 155 Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act 1. The authority citation for part 155 continues to read as follows: Authority: Title I of the Affordable Care Act, sections 1301, 1302, 1303, 1304, 1311, 1312, 1313, 1321, 1322, 1331, 1334, 1402, 1411, 1412, 1413. 2. Section 155.705 is amended by revising paragraphs (b)(2) through (4) to read as follows: § 155.705 Functions of a SHOP. * * * * * (b) * * * (2) Employer choice requirements. With regard to QHPs offered through the SHOP for plan years beginning on or after January 1, 2015, the SHOP must allow a qualified employer to select a level of coverage as described in section 1302(d)(1) of the Affordable Care Act, in which all QHPs within that level are made available to the qualified employees of the employer. (3) SHOP options with respect to employer choice requirements. (i) For plan years beginning before January 1, 2015, a SHOP may allow a qualified employer to make one or more QHPs available to qualified employees: (A) By the method described in paragraph (b)(2) of this section, or (B) By a method other than the method described in paragraph (b)(2) of this section. (ii) For plan years beginning on or after January 1, 2015, a SHOP: (A) Must allow an employer to make available to qualified employees all QHPs at the level of coverage selected by the employer as described in paragraph (b)(2) of this section, and (B) May allow an employer to make one or more QHPs available to qualified employees by a method other than the method described in paragraph (b)(2) of this section. (iii) For plan years beginning before January 1, 2015, a Federally-facilitated SHOP will provide a qualified employer the choice to make available to qualified employees a single QHP. (iv) For plan years beginning on or after January 1, 2015, a Federally-facilitated SHOP will provide a qualified employer a choice of two methods to make QHPs available to qualified employees: (A) The employer may choose a level of coverage as described in paragraph (b)(2) of this section, or (B) The employer may choose a single QHP. (4)(i) Premium aggregation. Consistent with the effective dates set forth in paragraph (b)(4)(ii) of this section, the SHOP must perform the following functions related to premium payment administration: (A) Provide each qualified employer with a bill on a monthly basis that identifies the employer contribution, the employee contribution, and the total amount that is due to the QHP issuers from the qualified employer; (B) Collect from each employer the total amount due and make payments to QHP issuers in the SHOP for all enrollees; and (C) Maintain books, records, documents, and other evidence of accounting procedures and practices of the premium aggregation program for each benefit year for at least 10 years. (ii) Effective dates. (A) A State-based SHOP may elect to perform these functions for plan years beginning before January 1, 2015, but need not do so. (B) A Federally-facilitated SHOP will perform these functions only in plan years beginning on or after January 1, 2015. * * * * * 3. Section 155.725 is amended by: A. Amending paragraph (a)(1) by adding “and” at the end of the paragraph. B. Amending paragraph (a)(2) by removing “; and” and by adding a period in its place at the end of the paragraph. C. Removing paragraph (a)(3), and D. Adding paragraph (j). The addition reads as follows: § 155.725 Enrollment periods under SHOP. * * * * * (j)(1) Special enrollment periods. The SHOP must provide special enrollment periods consistent with this section, during which certain qualified employees or a dependent of a qualified employee may enroll in QHPs and enrollees may change QHPs. (2) The SHOP must provide a special enrollment period for a qualified employee or dependent of a qualified employee who: (i) Experiences an event described in § 155.420(d)(1), (2), (4), (5), (7), (8), or (9); (ii) Loses eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a State child health plan under title XXI of the Social Security Act; or (iii) Becomes eligible for assistance, with respect to coverage under a SHOP, under such Medicaid plan or a State child health plan (including any waiver or demonstration project conducted under or in relation to such a plan). (3) A qualified employee or dependent of a qualified employee who experiences a qualifying event described in paragraph (j)(2) of this section has: (i) Thirty (30) days from the date of a triggering event described in paragraph (j)(2)(i) of this section to select a QHP through the SHOP; and (ii) Sixty (60) days from the date of a triggering event described in paragraph (j)(2)(ii) or (iii) of this section to select a QHP through the SHOP; (4) A dependent of a qualified employee is not eligible for a special election period if the employer does not extend the offer of coverage to dependents. (5) The effective dates of coverage are determined using the provisions of § 155.420(b). (6) Loss of minimum essential coverage is determined using the provisions of § 155.420(e). Part 156 Health Insurance Issuer Standards Under the Affordable Care Act Including Standards Related to Exchanges 4. The authority citation for part 156 continues to read as follows: Authority: Title I of the Affordable Care Act, sections 1301-1304, 1311-1312, 1321, 1322, 1324, 1334, 1341-1343, and 1401-1402, Pub l. 111-148, 124 Stat. 119 (42 U.S.C. 18042). 5. Section 156.285 is amended by revising paragraph (b)(2) to read as follows: § 156.285 Additional standards specific to SHOP. * * * * * (b) * * * (2) Provide special enrollment periods as described in § 155.725(j); * * * * * Dated: May 13, 2013. Marilyn Tavenner, Administrator, Centers for Medicare & Medicaid Services. Approved: May 15, 2013 Kathleen Sebelius, Secretary, Department of Health and Human Services. [FR Doc. 2013-13149 Filed 5-31-13; 11:15 am] BILLING CODE 4120-01-P http://www.regulations.gov/#!documentDetail;D=CMS_FRDOC_0001-1228

Implementation of information technology - related provisions of the Patient Protection and Affordable Care Act

Implementation of information technology - related provisions of the Patient Protection and Affordable Care Act

• Kurtin PLLC
• Owen D. Kurtin
• USA
• February 4 2013
• 

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With Patient Protection and Affordable Care Act (ACA) implementation obligations accelerating this year and in 2014, it is important to ensure that all healthcare providers have an appropriate implementation plan in place. The ACA includes a number of provisions regarding health Information Technology (IT) that address many of the challenges facing electronic health information exchange (HIE), as well as developing innovative new methods to reimburse expenses for quality care. These provisions can be categorized into three distinct groups. The first group of health IT-related provisions attempt to improve the quality of healthcare by increasing quality data collected by health IT, creating new programs that involve health IT, and giving payments to existing entities for the use and improvement of health IT. The second group of health IT-related provisions set new operating rules and standards that will directly or indirectly control the use and innovation of health IT. The third group of health IT-related provisions increases the size of the health IT workforce across different sectors. A summary of relevant ACA IT-oriented provisions for each group of provisions follows.

1. Healthcare Quality

Data Quality: The ACA includes the following provisions regarding quality reporting by healthcare providers. Health IT is a key tool among these provisions to efficiently improve the accuracy and expand the scope and type of data collected.

Section 2717: Directs the establishment of quality reporting requirements for group or individual health insurance issuers offering insurance.

Sections 3004 - 3005: Requires long-term care hospitals, inpatient rehabilitation hospitals, hospice programs and cancer hospitals to submit data on quality measures to the Heath and Human Services (HHS) Secretary.

Section 3013: Directs the establishment of new quality measures where no quality measures exist and to improve, update, and expand existing quality measures. The ACA defines a quality measure as a standard for measuring the improvement of population health or of health plans, service providers, and other clinicians in the delivery of health care services. The law requires grants to be awarded to entities for the purpose of developing quality measures that allow for the assessment of, among others, meaningful use of health IT, health disparities, and equity of health services.

Section 4302: Requires federally conducted or supported healthcare programs or surveys to collect and report demographic data, including ethnicity, sex, primary language, and disability status, as well as data at the smallest geographic level possible, such as state or local, etc. Requires HHS, with the Office of the National Coordinator (ONC), to develop national standards for data collection, and interoperability and security for data management systems.

Section 6301: Calls upon the Office of Communication and Knowledge Transfer to disseminate findings of government-sponsored research to groups such as, among others, vendors of health IT focused on clinical decision support. The Office must assist users of health IT so that the research is incorporated into clinical practices in a timely and efficient manner.

Section 10332: Requires claims data for items and services under Medicare parts A, B, and D to be made available for performance evaluations of providers and suppliers of healthcare services. Section 10333: Establishes grants to support the development of community-based collaborative care networks. Grants can be used for, among many things, telehealth services.

Section 10109: Directs the HHS Secretary to seek input on a variety of topics from such organizations as the National Committee on Vital and Health Statistics (NCVHS), the Health Information Technology Policy Committee, and the Health Information Technology Standards Committee, and standard setting organizations and stakeholders as determined appropriate.

Section 10305: requires the public reporting of performance information, which must be aligned with the expansion, interoperability efforts, and standard setting of health IT. Programs: The legislation establishes a host of new programs to foster quality healthcare. Health IT is a key factor in many of these new programs.

Section 1322: Creates the Consumer Operated and Oriented Plan (CO-OP) program to establish nonprofit health insurance companies. Organizations in the CO-OP program may enter into collective purchasing agreements for items and services such as health IT.

Section 1323: Requires the establishment of competitive and affordable community health insurance options offered through the Exchanges. The non-profit entities that will provide the community option shall, among other things, include procedures for the use of technology so that real-time data can be used to investigate indications of fraud and abuse.

Section 2401: Provides medical assistance for home and community-based services and support for eligible individuals, which should help in the accomplishment of activities of daily living and include back-up systems and mechanisms to ensure continuity of care

Section 2703: Provides medical assistance to eligible individuals with chronic conditions, who shall receive payments for the provision of home health services, which will include, among many things, care management and the use of health IT to combine services.

Section 3011: Required the HHS Secretary to create a national strategy to improve the delivery of healthcare services, patient outcomes, and population health by January 1, 2011. This national plan was required to be integrated with the quality improvements and measurements for health IT required by the American Recovery and Reinvestment Act (ARRA) of 2009.

Section 4103: Creates an “Annual Wellness Visit” for each Medicare beneficiary, who will be encouraged to increase self-management skills and management of and adherence to provider recommendations through the use of health IT and other personalized technology.

Section 5405: Establishes the “Primary Care Extension Program” which will educate and provide technical assistance to primary care providers about evidence-based practices and disseminate research findings. To carry out this program, the HHS Secretary will consult with agencies experienced in health care and preventative care, including the ONC.

Section 5604: Establishes grants for qualified community mental health programs to, among many things, provide health IT for healthcare professionals. Section 6701: Establishes grants for long-term care facilities to assist in the purchase, lease, development, and implementation of certified EHR technology. Electronic standards must be adopted for the exchange of clinical data between longterm care facilities.

Section 10410: Makes available grants to eligible entities to establish national centers of excellence for depression, which are required to, among other things, use electronic health records and telehealth technology to coordinate, manage, and improve access to healthcare. Reimbursement Structures: The legislation aims to reward providers for demonstrating the delivery of quality healthcare. Health IT will be a key component in the process.

Section 1311: Creates state-based American Health Benefit Exchanges through which individuals and small businesses can purchase health insurance. Increased reimbursement will be developed for providers who implement, among many things, best clinical practices, evidence based medicine, and health IT to improve patient safety and reduce medical errors.

Section 2706: Establishes the Pediatric Accountable Care Organization (ACO) Demonstration Project to recognize pediatric medical providers as ACOs for the purpose of receiving incentive payments. A minimal level of savings must be reached to receive the payment. Section 3002: Extends the Physician Quality Reporting Initiative (PQRI) program to 2014, integrates the quality reporting measures within the PQRI with reporting requirements for meaningful use of electronic health records, and establishes an informal review process.

Section 3021: Creates the Center for Medicare and Medicaid Innovation (CMI), which will test innovative payment and service delivery models. These models are intended to support care coordination for patients through the use of a health IT-enabled network.

Section 3022: Creates a “shared savings program” that encourages the investment in infrastructure and redesigned care processes for high quality and efficient service delivery. Healthcare providers may manage and coordinate care for Medicare beneficiaries through an ACO), which can be eligible to receive payments for shared savings. An ACO is required to, among many things, promote evidence-based medicine and coordinate care through the use of telehealth and other enabling technologies. Section 3024: Requires the test of a payment incentive and delivery service model that reduces costs by creating physician and nurse practitioner directed home-based primary care teams. These teams will employ, among many things, electronic health information systems. Teams who employ, among others, EMR and health IT will receive preference for approval.

Section 3201: Establishes bonus payments to Medicare Advantage Plans that conduct, among many things, clinical decision support and data collection using health IT systems.

2. Operating Rules and Standards

Section 1104: Establishes a single set of operating rules regarding eligibility and claims status, electronic funds transfers, healthcare payment and remittance rules, health claims, enrollment in health plans, health plan premium payments, referral authorizations, and unique health plan identifiers, for the purpose of simplifying the administration of healthcare. The operating rules will be consensus-based and will reflect the business rules of health plans and healthcare providers, as well as operation under the standards issued under HIPAA. The NCVHS will advise the HHS Secretary on the process, and audits will be performed to ensure that health plans are in compliance. A Review Committee will review the adopted standards and, when appropriate, will coordinate between the EHR standards approved by the ONC.

Section 1561: Requires the HHS Secretary and the HIT Policy and Standards Committees to develop interoperable and secure standards for the enrollment of individuals in Federal and State health service programs. These standards must allow for electronic matching against existing data, simplification of documentation, reuse of stored eligibility information, capability for individuals to manage information online, integration with new programs and rules, and other functionalities necessary to streamline the process. The HHS Secretary retains the option to require States to implement these standards in order to receive Federal funding for health IT investments, and is required to award grants to eligible entities for the purpose of developing new or adapting existing health IT so that compliance with standards is reached. The eligible entities are then required to share any developed technology and/or other information.

3. Health IT Workforce

Section 2801: Updates the membership composition of the Medicaid and CHIP Payment and Access Commission (MACPAC) to include individuals who have had direct experience in, among many things, health IT. Section 3012: Establishes the “Interagency Working Group on Health Quality,” which will collaborate with Federal departments and agencies, disseminate strategies and models, avoid duplication, and assess the quality of the public sector. The group will be made up of representatives from organizations such as HHS, CMS, CDC, AHRQ, and ONC.

Section 3501: Establishes the Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality (AHRQ). The Center will identify, develop, and disseminate innovative methodologies and strategies for quality improvement practices, including, among other things, the expansion of health IT into childrenʼs healthcare.

Section 3502: Creates community-based interdisciplinary “health teams” to provide support services to primary care practices within a hospital service area. These health teams must demonstrate a capacity to implement and maintain health IT that meets certification.

Section 5101: Establishes the “National Healthcare Workforce Committee” that communicates between Departments, develops education and training, disseminates information on policies that affect recruitment and retention of the workforce, and identifies barriers to coordination. The Committee should address a range of healthcare topics, including the increased demand for workers in the enhanced IT and management workplace.

Section 5301: Supports the development of primary care training and enhancement programs, such as capacity building in primary care. The HHS Secretary should award grants to entities that fulfill some categories, such as providing training in evidence-based practice and health IT. Section 6114: Requires the HHS Secretary to conduct two projects, one of which updates nursing practices and facilities for the use of health information technology to improve care.