[Federal Register Volume 76, Number 178 (Wednesday, September 14, 2011)]
[Notices]
[Pages 56767-56770]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-23388]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-9980-NC]
Request for Information Regarding State Flexibility To Establish
a Basic Health Program Under the Affordable Care Act
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Request for information.
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SUMMARY: This notice is a request for information regarding section
1331 of the Affordable Care Act, which provides States with the option
to establish a Basic Health Program. This option permits States to
enter into contracts to offer one or more ``standard health plans''
providing at least the essential health benefits described in section
1302(b) of the Affordable Care Act to eligible individuals in lieu of
offering such individuals coverage through the Affordable Insurance
Exchange (Exchange).
DATES: Comment Date: To be assured consideration, responses must be
received at one of the addresses provided below, no later than 5 p.m.
on October 31, 2011.
ADDRESSES: In responding, please refer to file code CMS-9980-NC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit responses in one of four ways (please choose only
one of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the instructions under
the ``More Search Options'' tab.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-9980-NC, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-9980-NC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
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b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call telephone number (410) 786-9994 in advance to schedule your
arrival with one of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Shaina Rood, (301) 492-4422.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
I. Background
Section 1331(a) of the Patient Protection and Affordable Care Act
(Pub. L. 111-148), as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. 111-152), referred to collectively
as the Affordable Care Act, directs the Secretary of Health and Human
Services (the Secretary) to establish a Basic Health Program under
which States may enter into contracts with one or more standard health
plans that provide health coverage to eligible individuals in lieu of
offering such individuals coverage through the Exchange. For States
choosing this option, section 1331(a)(2) of the Affordable Care Act
provides that the Secretary certify that the amount of the monthly
premium charged to eligible individuals enrolled in a plan under
contract under this program, called a standard health plan, does not
exceed the amount of the monthly premium that an eligible individual
would have paid if he or she were to receive coverage from the
applicable benchmark plans (as defined in section 36B(b)(3)(B) of the
Internal Revenue Code of 1986) through the Exchange. This section also
directs the Secretary to certify that cost-sharing does not exceed the
standards specified in section 1331(a)(2)(A)(ii) of the Affordable Care
Act.
Section 1331(b) of the Affordable Care Act defines a standard
health plan as one selected by the State that: (1) Only enrolls
applicants who are determined eligible using the eligibility standards
specified in section 1331(e) of the Affordable Care Act; (2) covers at
least the essential health benefits described in section 1302(b) of the
Affordable Care Act; and (3) in the case of a plan that provides health
insurance coverage offered by a health insurance issuer, has a medical
loss ratio of at least 85 percent.
Section 1331(c) of the Affordable Care Act specifies that a Basic
Health Program will establish a competitive process for entering into
contracts with standard health plans, including negotiation of
premiums, cost-sharing, and benefits in addition to the essential
health benefits. The statute provides that the State include in its
competitive process the inclusion of innovative features such as care
coordination and care management for enrollees, incentives for the use
of preventive services, and the establishment of relationships between
providers and patients that maximize patient involvement in health care
decision-making. The contracting process shall also take into
consideration, and make suitable allowances for, the differences in the
health care needs of enrollees and the differences in local
availability of, and access to, health care providers.
Section 1331(c)(2) of the Affordable Care Act provides that the
competitive process shall also include contracting with managed care
systems, or with systems that offer as many of the attributes of
managed care as are feasible in the local health care market. The
competitive contracting process shall also include the establishment of
specific performance measures and standards for issuers that focus on
quality of care and improved health outcomes. Section 1331(c)(3)
provides that a State shall, to the maximum extent feasible, seek to
make multiple standard health plans available to ensure individuals
have a choice of such plans. It also provides that a State may
negotiate a regional compact with other States to include coverage of
eligible individuals in all such States in agreements with issuers of
standard health plans.
Section 1331(c)(4) of the Affordable Care Act directs a State
choosing to establish a Basic Health Program to coordinate the
administration of a Basic Health Program with Medicaid, the Children's
Health Insurance Program (CHIP), and other State-administered health
programs.
Section 1331(d)(1) of the Affordable Care Act allows the Secretary
to transfer Federal funds to a State that establishes a Basic Health
Program in accordance with the standards of the program under section
1331(a). Section 1331(d)(2) of the Affordable Care Act directs that a
State establish a trust fund for the deposit of the Federal funds it
receives for its Basic Health Program, and specifies that the amounts
in the trust may only be used to reduce the premiums and cost-sharing
of, or to provide additional benefits for, eligible individuals
enrolled in standard health plans within a Basic Health Program.
Section 1331(d)(3) of the Affordable Care Act specifies that a
State that operates a Basic Health Program will receive 95 percent of
the amount of premium tax credits, and the cost-sharing reductions,
that would have been provided to (or on behalf of) eligible individuals
enrolled in standard health plans through a Basic Health Program, if
the eligible individuals were instead enrolled in qualified health
plans (QHP) through the Exchange and receiving premium tax credits and
cost-sharing reductions. To determine the amount of payment, the
Secretary shall take into account all relevant factors necessary to
determine the amount that would have been provided to eligible
individuals as specified in 1331(d)(3), including, but not limited to,
whether any reconciliation of the credit or cost-sharing reductions
would have occurred if the enrollee had been so enrolled.
Section 1331(d)(3) also provides that the determination shall also
take into consideration the experience of other States with respect to
participation in an Exchange and such credits and reductions provided
to residents of the other States, with a special focus on enrollees
with income below 200 percent of poverty. Additionally, the Secretary
shall adjust the amount of payment for any fiscal year to reflect any
error in the determinations for any preceding fiscal year.
Section 1331(e) of the Affordable Care Act specifies eligibility
standards for a Basic Health Program. To be determined
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eligible for a Basic Health Program, an individual must:
(1) Be a resident of a State participating in a Basic Health
Program;
(2) Be eligible for enrollment in a QHP through the Exchange but
for the existence of a Basic Health Program;
(3) Not be eligible to enroll in the State's Medicaid program under
title XIX of the Social Security Act (the Act), for benefits that at a
minimum consist of the essential health benefits described in section
1302(b) of the Act;
(4) Have a household income that exceeds 133 percent but does not
exceed 200 percent of the Federal poverty level (FPL), or, for a non-
citizen lawfully present who is not eligible for Medicaid based on
immigration status, a household income that is not greater than 133
percent of the FPL;
(5) Not be eligible for minimum essential coverage or is eligible
for an employer-sponsored plan that is not affordable coverage; and
(6) Not have attained age 65 as of the beginning of the plan year.
Section 1331(f) of the Affordable Care Act directs the Secretary to
conduct an annual review of each State Basic Health Program to ensure
that it complies with the standards of section 1331. Through this
annual review, the State will provide information to demonstrate that
its Basic Health Program meets: (1) Eligibility verification standards
for participation in the program; (2) standards for the use of Federal
funds received by the program; and (3) quality and performance
standards.
As specified in section 1331(g) of the Affordable Care Act, a
standard health plan offeror may be a licensed health maintenance
organization, a licensed health insurance insurer, or a network of
health care providers established to offer services under the program;
the statute provides authority for the State to determine eligibility
to offer a standard health plan.
II. Request for Information
Section 1321(a)(2) of the Affordable Care Act directs the Secretary
to consult with stakeholders to ensure balanced representation among
interested parties in issuing regulations to implement programs
pursuant to title I. The Department of Health and Human Services has
consulted with stakeholders through regular meetings with the National
Association of Insurance Commissioners, regular contact with States
through the Exchange grant process, and meetings with tribal
representatives, health insurance issuers, trade groups, consumer
advocates, employers, and other interested parties. This consultation
will continue throughout the development of guidance and regulations
related to the Basic Health Program.
As such, we are requesting information to aid in the development of
standards for the establishment and operation of a Basic Health
Program. To assist in responding, this request for information
describes the specific areas where input is particularly requested.
Specifically, we ask for responses to the questions below to
provide the Secretary with relevant information for the development of
guidance and regulations regarding the Basic Health Program. However,
it is not necessary for respondents to address every question below and
respondents may also address additional issues about the Basic Health
Program that are not listed here. Individuals, groups, and
organizations interested in providing responses may do so at their
discretion by following the above mentioned instructions.
A. General Provisions
1. What are some of the major factors that States are likely to
consider in determining whether to establish a Basic Health Program?
Are there additional flexibilities, advantages, costs, savings or
challenges for the State and/or consumer that would make this option
more or less attractive to States? If so, what are they?
2. What are key considerations for States in placing responsibility
for a Basic Health Program within the State organizational structure?
3. What are the challenges and costs associated with managing a
Basic Health Program?
4. Are States that are exploring the Basic Health Program
considering implementation for 2014, or for later years? What are the
key tasks that need to be accomplished, and within what timeframes, to
implement the Basic Health Program in a timely fashion? What kinds of
business functions will need to be operational before implementation,
and how soon will they need to be operational? Are there opportunities
to leverage existing systems and increase efficiency within the State
structure? To what extent have States begun developing business plans
or budgets relating to Basic Health Program implementation?
5. To what extent have States already begun to assess whether to
establish a Basic Health Program? What internal and/or external
entities are involved, or will likely be involved in this planning
process?
6. What guidance or information would be helpful to States, plans,
and other stakeholders as they begin the planning process? What other
terms or provisions need additional clarification to facilitate
implementation and compliance? What specific clarifications would be
helpful?
7. How can the Administration provide technical assistance? What
form(s) of technical assistance would be most helpful to States?
B. Standard Health Plan Standards and Standard Health Plan Offerors
1. What additional standards, if any, should standard health plans
participating in a State's Basic Health Program meet? What consumer
protections should be included? How should quality and performance be
measured?
2. What plan design issues should be considered? How likely is it
for a State to consider an expanded benefit package beyond the
essential health benefits for standard health plans participating in a
State's Basic Health Program? What are the advantages and disadvantages
of an expanded benefit package for standard health plans compared to
qualified health plans?
3. What is the expected impact of standard health plans on provider
payments and consumer access?
C. Contracting Process
1. What innovative features should States consider when negotiating
through the contracting process with standard health plans to
participate in a Basic Health Program?
2. What considerations exist in determining whether to utilize the
regional compact authority in Section 1331(c)(3)(B) of the Affordable
Care Act? Are States interested in pursuing this approach?
D. Coordination With Other State Programs
1. What is the expected impact of a Basic Health Program on the
Exchange's purchasing power and viability? How might States organize a
Basic Health Program with respect to purchasing structure?
2. What is the expected impact of a Basic Health Program on plans
participating in the Exchange in terms of risk profile, enrollment, and
premium stability? What is the expected impact on overall coverage?
3. What are some of the major factors that States are likely to
consider in determining how to structure their Basic Health Program?
Are States likely to structure the Basic Health Program as one
component of its other public
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programs? Are States likely to consider a CHIP-like approach or other
options? What are the pros and cons of these various options?
4. How can eligibility and enrollment be effectively coordinated
between the Basic Health Program and other State programs to reduce
churning between programs and promote continuity of care?
5. How could establishing a Basic Health Program affect the ability
of an entire family to be covered by the same plan?
6. Are standard health plans likely to also participate in other
coverage programs, such as the Exchanges, Medicaid, or CHIP? Should
this be encouraged, and if so, how could CMS and States encourage it?
E. Amount of Payment
1. The statute specifies that amounts in the trust fund may only be
used to reduce the premiums and cost-sharing of, or to provide
additional benefits for, eligible individuals enrolled in standard
health plans within a Basic Health Program. What options are States
considering for reducing premiums and cost-sharing, or providing
additional benefits? What, if any, guidance is needed on this
provision?
2. What are the likely administrative costs for a Basic Health
Program? What factors, especially in terms of resources, are likely to
affect a State's ability to establish a Basic Health Program? How are
States likely to fund the costs associated with establishing and
administering a Basic Health Program?
3. The statute specifies that in developing the financial
methodology for the Basic Health Program, the determination of the
value of the premium tax credits and cost-sharing reductions should
take into consideration the experience of other States. What
information would be most helpful to inform this methodology? Should
implementation of the Basic Health Program be postponed until other
States' experiences are available?
4. Other than those listed in the statute, what factors should be
considered when establishing the methodology for determining the amount
of Basic Health Program funding to States? How should the Federal
government implement this calculation?
5. The statute specifies that the funding calculation is on a per-
enrollee basis. How should the Federal government acquire the detailed
information necessary to perform this calculation?
6. What are the best State-specific data sources to use in
estimating the availability of affordable employer-sponsored insurance?
7. What methods should be considered to measure and monitor
compliance with the 95 percent cap on funding? How should CMS implement
the provisions in Section 1331(d)(3)(B) of the Affordable Care Act
regarding corrections to overpayments made in any year?
F. Eligibility
1. What education and outreach will be necessary to facilitate a
helpful consumer experience?
G. Secretarial Oversight
1. What process should the Secretary use to certify or recertify
Basic Health Programs? How should this process be similar to or
different from Exchange certification?
2. What should be considered when developing an oversight process
for the Basic Health Program?
Authority: Catalog of Federal Domestic Assistance Program No.
93.773, Medicare--Hospital Insurance; and Program No. 93.774,
Medicare--Supplementary Medical Insurance Program.
Dated: July 27, 2011.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2011-23388 Filed 9-9-11; 11:15 am]
BILLING CODE 4120-01-P