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I'm not actually in the bathtub, but I thought I would read and make more notes...
In my last post, I scanned a lot of the first part of the document, then used the browser's "find" function to find the word "agent". That's why most of my notes started with page 56 in that post. So this time, I started from the beginning of the document.
Pages 5-7 has a great list of acronyms that any newbie to PPACA should definitely review.
Page 13 - I thought I remembered that this was in the law... I wonder how Assurant and GR/UH1 are saying they will segregate the current non-grandfathered plans? Section 1312(c) of the Affordable Care Act directs a health insurance issuer to consider
all enrollees in all health plans (other than grandfathered health plans) offered by such issuer to be members of a single risk pool for each of its individual and small group markets. Section 1312(c) of the Affordable Care Act gives States the option to merge the individual and small group markets within the State into a single risk pool.
Page 13 - Again confirms that they allow agents & brokers to assist with the subsidy application (advance premium tax credit) as well as the enrollment into coverage. Section 1312(e) of the Affordable Care Act directs the Secretary to establish procedures under which a State may permit agents and brokers to enroll qualified individuals and qualified employers in QHPs through an Exchange, and to assist individuals in applying for advance payments of the premium tax credit and cost-sharing reductions. Like I said in the last post, that doesn't mean you are REQUIRED to, just that they allow agents to assist with the subsidy apps.
Page 15 - so much for that aforementioned idea of lying to obtain subsidies, then having a clawback that is limited! Section 1411(h) of the Affordable Care Act sets forth civil penalties that any person will be subject to if a person provides inaccurate information as part of the application or improperly
uses or discloses information
Page 15-16 - Important reference for looking up the regulations later. They say the regs will be codified in 45 CFR parts 144,
147, 153, 155, and 156. It says Part 155 will include State standards applying to agents and brokers.
Pages 17-18 - Someone smarter than me needs to interpret whether these paragraphs are important. They are redefining (or perhaps clarifying) small group, large group, association plans, group plans with less than 2 participants and policy year in this section. The "policy year" quote is "we propose to amend the definition of “policy year” with respect to nongrandfathered coverage in the individual market or in a market in which the State has merged the individual and small group risk pools, pursuant to section 1312(c)(3) of the Affordable Care Act and implementing regulations at 45 CFR 156.80(c). Under this proposal, “policy year” means a calendar year for which health insurance coverage provides coverage for health benefits. This is consistent with the proposed technical clarification to §147.104 discussed below"
Pages 19-20 - HHS has received several inquiries... asking whether geographic rating in the small group market is based on employee or employer address. HHS has also received several inquiries asking which rating areas should be used for individual market coverage if family members live in multiple locations. PHS Act section 2701(a)(4) and §147.102(c) require any rating variation for age and tobacco use to be applied on a per-member basis, but do not impose the same requirement on rating for geography. Accordingly, consistent with guidance released on April 26, 2013 describing our intended clarification, we propose to clarify in §147.102(a)(1)(ii) that the rating area is determined in the small group market using the principal business address of the group policyholder, and in the individual market, using the address of the primary policyholder, regardless of the location of other individuals covered under the plan or coverage. This would apply both inside and outside of the Exchange and SHOP.
Pages 20-21 is a long winded way of saying plans must have guarantee availability and guaranteed renewability in all 3 market segments (IFP, small group & large group), however only within its own market segment (for instance a product designed for large group does not have to be guarantee available to small group).
Page 22 - someone please clarify what this means, but it appears to mean that staggered renewal dates are over as of 1/1/2015. Also, in §147.104(b)(2), we propose a clarification that, as of January 1, 2015, all nongrandfathered coverage in the individual market or in a market in which the State has merged the individual and small group risk pools, pursuant to section 1312(c)(3) of the Affordable Care Act and implementing regulations at 45 CFR 156.80(c), must be offered on a calendar year basis. This simply clarifies the intent of the Market Reform Rule. It is essential that all nongrandfathered coverage in the individual and merged markets be on a calendar year basis as of
January 1, 2015 to line up with coverage in the Exchanges and also to be consistent with the requirements of the single risk pool in §156.80. For purposes of new enrollment effective on any
date other than January 1, the first policy year following such enrollment may comprise a prorated policy year, ending on December 31.
Pages 32 & 33 - once again confirms that the premium is based on the first 3 kids (under age 21) in most states. ...In the case of families with more than three children in non-community rated States, only the applicable rates of the three oldest covered children under age 21 are counted towards the family policy premium rate (for example, for a family with four
children under age 21, only the applicable individual rates of the three oldest children would count towards the family policy premium). These family rating requirements do not apply to
community rated States that utilize family tiering rating factors...
Pages 22-46 are really about risk adjustment and corridors, but anyone planning to do self-insured plans, or a combination of non-major medical plans for groups that constitute full major medical coverage might want to read this. As part of this risk adjustment segment, HHS mentioned that they might be making a clarification of the definition of "major medical" as it applies to this section. If they do clarify that definition, that might apply to other sections, and that is an important issue to those of us who hope that the carriers will create beefed up fixed indemnity plans with a quality range of covered services, which is not currently considered major medical, and is therefore not subject to many of the PPACA rules. Page 38 - We are also considering proposing a definition for “major medical coverage” that would provide additional clarity around the responsibility to make payments Note that by saying "clarity around the responsibility to make payments" they mean reinsurance and risk adjustment payments that all major medical plans must contribute to.
Pages 46-79 are pages I covered in my last post, so I will skip them here.
Page 79 - this is regarding the SHOP exchange for group plans, but it confirms what Somarco was saying on a post about the carriers' ability to change their rates more often than annually. Just one part of this paragraph says, "...require QHP
issuers to make changes to rates at a uniform time that is no more frequently than quarterly
Page 90 - we have a new title! Delegated entity
We propose to define a delegated entity as any party, including an agent or a broker that enters into an agreement with a QHP issuer to provide administrative services or health care services to qualified individuals, qualified employers, or qualified mployees and their dependents
Page 90 - and another title! Downstream entity
We propose to define a downstream entity as any party, including an agent or a broker, that enters into an agreement with a delegated entity or with another downstream entity for
purposes of providing administrative or health care services related to the agreement between the delegated entity and the QHP issuer. The term “downstream entity” is intended to reach the entity that directly provides administrative services or health care services to qualified individuals, qualified employers, or qualified employees and their dependents.
Pages 91-92. Okay.... Hmmmm.... previously they said carriers could adjust rates quarterly, but also said this would be addressed later in the document. It's addressed in length here. Basically, it is saying that the IFP market can only adjust annually, and most states merged IFP and small group risk pools, that means small group can only adjust annually. Then it says small group should be able to adjust quarterly, but since the exchange can't handle that, they can only adjust annually for now. Here's a snippet that seems to sum it up. Accordingly, in order to align with the timing of the adjustments permitted in the SHOP based on these operational considerations, issuers would be required under the amendment to this section to set rates for non-grandfathered plans in the small group market on an annual basis market-wide until the FFSHOPs’ capability to process quarterly rate updates is established. We anticipate that the FFSHOPs will be capable of processing quarterly updated rates effective for the third quarter of 2014. Also, they note that when rates change it affects new and renewal business, so there can't be attractive new-business rates versus aging pool rates, as Somarco had mentioned earlier. Someone smarter than me needs to read this and/or the sources referenced in this section to tell us if the IFP market can change rates more often than annually. Somarco?
Pages 94-96 - Read this at your leisure. It's about "Downstream and Delegated Entities", which includes agents and brokers. Basically, it's saying our "upstream" (meaning the carrier) must put in the contracts that the downstream will comply with all the rules and standards. This section references their Medicare Advantage rules often, which has this kind of language in it.
And, with that I'm done for the night. It's 11 pm. Good night, everyone.
In my last post, I scanned a lot of the first part of the document, then used the browser's "find" function to find the word "agent". That's why most of my notes started with page 56 in that post. So this time, I started from the beginning of the document.
Pages 5-7 has a great list of acronyms that any newbie to PPACA should definitely review.
Page 13 - I thought I remembered that this was in the law... I wonder how Assurant and GR/UH1 are saying they will segregate the current non-grandfathered plans? Section 1312(c) of the Affordable Care Act directs a health insurance issuer to consider
all enrollees in all health plans (other than grandfathered health plans) offered by such issuer to be members of a single risk pool for each of its individual and small group markets. Section 1312(c) of the Affordable Care Act gives States the option to merge the individual and small group markets within the State into a single risk pool.
Page 13 - Again confirms that they allow agents & brokers to assist with the subsidy application (advance premium tax credit) as well as the enrollment into coverage. Section 1312(e) of the Affordable Care Act directs the Secretary to establish procedures under which a State may permit agents and brokers to enroll qualified individuals and qualified employers in QHPs through an Exchange, and to assist individuals in applying for advance payments of the premium tax credit and cost-sharing reductions. Like I said in the last post, that doesn't mean you are REQUIRED to, just that they allow agents to assist with the subsidy apps.
Page 15 - so much for that aforementioned idea of lying to obtain subsidies, then having a clawback that is limited! Section 1411(h) of the Affordable Care Act sets forth civil penalties that any person will be subject to if a person provides inaccurate information as part of the application or improperly
uses or discloses information
Page 15-16 - Important reference for looking up the regulations later. They say the regs will be codified in 45 CFR parts 144,
147, 153, 155, and 156. It says Part 155 will include State standards applying to agents and brokers.
Pages 17-18 - Someone smarter than me needs to interpret whether these paragraphs are important. They are redefining (or perhaps clarifying) small group, large group, association plans, group plans with less than 2 participants and policy year in this section. The "policy year" quote is "we propose to amend the definition of “policy year” with respect to nongrandfathered coverage in the individual market or in a market in which the State has merged the individual and small group risk pools, pursuant to section 1312(c)(3) of the Affordable Care Act and implementing regulations at 45 CFR 156.80(c). Under this proposal, “policy year” means a calendar year for which health insurance coverage provides coverage for health benefits. This is consistent with the proposed technical clarification to §147.104 discussed below"
Pages 19-20 - HHS has received several inquiries... asking whether geographic rating in the small group market is based on employee or employer address. HHS has also received several inquiries asking which rating areas should be used for individual market coverage if family members live in multiple locations. PHS Act section 2701(a)(4) and §147.102(c) require any rating variation for age and tobacco use to be applied on a per-member basis, but do not impose the same requirement on rating for geography. Accordingly, consistent with guidance released on April 26, 2013 describing our intended clarification, we propose to clarify in §147.102(a)(1)(ii) that the rating area is determined in the small group market using the principal business address of the group policyholder, and in the individual market, using the address of the primary policyholder, regardless of the location of other individuals covered under the plan or coverage. This would apply both inside and outside of the Exchange and SHOP.
Pages 20-21 is a long winded way of saying plans must have guarantee availability and guaranteed renewability in all 3 market segments (IFP, small group & large group), however only within its own market segment (for instance a product designed for large group does not have to be guarantee available to small group).
Page 22 - someone please clarify what this means, but it appears to mean that staggered renewal dates are over as of 1/1/2015. Also, in §147.104(b)(2), we propose a clarification that, as of January 1, 2015, all nongrandfathered coverage in the individual market or in a market in which the State has merged the individual and small group risk pools, pursuant to section 1312(c)(3) of the Affordable Care Act and implementing regulations at 45 CFR 156.80(c), must be offered on a calendar year basis. This simply clarifies the intent of the Market Reform Rule. It is essential that all nongrandfathered coverage in the individual and merged markets be on a calendar year basis as of
January 1, 2015 to line up with coverage in the Exchanges and also to be consistent with the requirements of the single risk pool in §156.80. For purposes of new enrollment effective on any
date other than January 1, the first policy year following such enrollment may comprise a prorated policy year, ending on December 31.
Pages 32 & 33 - once again confirms that the premium is based on the first 3 kids (under age 21) in most states. ...In the case of families with more than three children in non-community rated States, only the applicable rates of the three oldest covered children under age 21 are counted towards the family policy premium rate (for example, for a family with four
children under age 21, only the applicable individual rates of the three oldest children would count towards the family policy premium). These family rating requirements do not apply to
community rated States that utilize family tiering rating factors...
Pages 22-46 are really about risk adjustment and corridors, but anyone planning to do self-insured plans, or a combination of non-major medical plans for groups that constitute full major medical coverage might want to read this. As part of this risk adjustment segment, HHS mentioned that they might be making a clarification of the definition of "major medical" as it applies to this section. If they do clarify that definition, that might apply to other sections, and that is an important issue to those of us who hope that the carriers will create beefed up fixed indemnity plans with a quality range of covered services, which is not currently considered major medical, and is therefore not subject to many of the PPACA rules. Page 38 - We are also considering proposing a definition for “major medical coverage” that would provide additional clarity around the responsibility to make payments Note that by saying "clarity around the responsibility to make payments" they mean reinsurance and risk adjustment payments that all major medical plans must contribute to.
Pages 46-79 are pages I covered in my last post, so I will skip them here.
Page 79 - this is regarding the SHOP exchange for group plans, but it confirms what Somarco was saying on a post about the carriers' ability to change their rates more often than annually. Just one part of this paragraph says, "...require QHP
issuers to make changes to rates at a uniform time that is no more frequently than quarterly
Page 90 - we have a new title! Delegated entity
We propose to define a delegated entity as any party, including an agent or a broker that enters into an agreement with a QHP issuer to provide administrative services or health care services to qualified individuals, qualified employers, or qualified mployees and their dependents
Page 90 - and another title! Downstream entity
We propose to define a downstream entity as any party, including an agent or a broker, that enters into an agreement with a delegated entity or with another downstream entity for
purposes of providing administrative or health care services related to the agreement between the delegated entity and the QHP issuer. The term “downstream entity” is intended to reach the entity that directly provides administrative services or health care services to qualified individuals, qualified employers, or qualified employees and their dependents.
Pages 91-92. Okay.... Hmmmm.... previously they said carriers could adjust rates quarterly, but also said this would be addressed later in the document. It's addressed in length here. Basically, it is saying that the IFP market can only adjust annually, and most states merged IFP and small group risk pools, that means small group can only adjust annually. Then it says small group should be able to adjust quarterly, but since the exchange can't handle that, they can only adjust annually for now. Here's a snippet that seems to sum it up. Accordingly, in order to align with the timing of the adjustments permitted in the SHOP based on these operational considerations, issuers would be required under the amendment to this section to set rates for non-grandfathered plans in the small group market on an annual basis market-wide until the FFSHOPs’ capability to process quarterly rate updates is established. We anticipate that the FFSHOPs will be capable of processing quarterly updated rates effective for the third quarter of 2014. Also, they note that when rates change it affects new and renewal business, so there can't be attractive new-business rates versus aging pool rates, as Somarco had mentioned earlier. Someone smarter than me needs to read this and/or the sources referenced in this section to tell us if the IFP market can change rates more often than annually. Somarco?
Pages 94-96 - Read this at your leisure. It's about "Downstream and Delegated Entities", which includes agents and brokers. Basically, it's saying our "upstream" (meaning the carrier) must put in the contracts that the downstream will comply with all the rules and standards. This section references their Medicare Advantage rules often, which has this kind of language in it.
And, with that I'm done for the night. It's 11 pm. Good night, everyone.
