Regulations and Mandates that Affect Your Business
Every year SSDC exchanges over 36 million records with the Centers for Medicare and Medicaid Services (CMS). Our unique relationship and experience with CMS provides us with insight on new regulations and mandates that may affect your business, including the following:
Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010
No legislation over the past 50 years has been as encompassing as the new Patient Protection and Affordable Care Act of 2010. This legislation impacts every single person in the United States and has significant implications for corporations and individuals.
A summary of the legislation provided by the America's Health Insurance Plan (AHIP) can be found in PDF form at the right side of this page. Some of the major highlights affecting corporations in this legislation are as follows:
- Group Health Plans are prohibited from rescinding coverage once the plan has been issued. Rescission can only be in the case of fraud or intentional misrepresentation
- Group Health Plans are prohibited from imposing any preexisting condition exclusion on coverage
- Limits unreasonable premium increases
- Extends coverage for dependant adult children up to the age of 26 years old
- Establishes a temporary reinsurance program for early retirees and their spouses between the ages of 55 and 64, who are not Medicare eligible, to reimburse health care claims for 80 percent of that portion between $15,000 and $90,000 adjusted annually
- Tax-free subsidies for prescription drugs will continue, employers receiving them will no longer be allowed to take a tax deduction for prescription drug expenses equal to the amount of the subsidy
- Maximum period for submission of Medicare claims reduced to not more than 12 months (down from a total possible 27 months in years past)
All of these changes and many more located within the legislation will have an impact on both business and individuals. Be prepared and know how it will affect you.
- AHIP Summary of the Senate "Patient Protection and Affordable Care Act"
DEPARTMENT OF HEALTH AND HUMAN SERVICES, Early Retiree Reinsurance Program, 45 CFR Part 149
SUMMARY: This interim final rule with comment period (IFC) implements the Early Retiree Reinsurance Program, which was established by section 1102 of the Patient Protection and Affordable Care Act (the Affordable
Care Act). The Congress appropriated funding of $5 billion for the temporary program. Section 1102(a)(1) requires the Secretary to
establish this temporary program not later than 90 days after enactment of the statute, which is June 21, 2010. The program ends no later than
January 1, 2014. The program provides reimbursement to participating employment-based plans for a portion of the cost of health benefits for
early retirees and their spouses, surviving spouses and dependents. The Secretary will reimburse plans for certain claims between $15,000 and
$90,000 (with those amounts being indexed for plan years starting on or after October 1, 2011). The purpose of the reimbursement is to make
health benefits more affordable for plan participants and sponsors so that health benefits are accessible to more Americans than they would
otherwise be without this program.
DATES: Effective Date: These regulations are effective on June 1, 2010.
Additional information can be found here: http://edocket.access.gpo.gov/2010/2010-10658.htm
Medicare, Medicaid and SCHIP Extension Act
The following Mandatory Insurer Reporting Requirements (MIRR) regulation is the latest release from the Government pertaining to the Medicare, Medicaid and SCHIP Extension Act (MMSEA) of 2007. More information about its requirements can be found at the Centers for Medicare and Medicaid Services web site.
Mandatory Insurer Reporting Requirements of Section 111 of the
Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA)
“Effective January 1, 2009, as required by Section 111 of the Medicare, Medicaid and SCHIP Act of 2007 (MMSEA), an entity serving as an insurer or third party administrator for a group health plan and, in the case of a group health plan that is self-insured and self-administered, a plan administrator or fiduciary must: (1) Secure from the plan sponsor and plan participants such information as the Secretary may specify to identify situations where the group health plan is a primary plan to Medicare; and (2) report such information to the Secretary in the form and manner (including frequency) specified by the Secretary”. An entity, a plan administrator, or a fiduciary that fails to comply with the requirements shall be subject to a civil money penalty of $1,000 for each day of noncompliance for each individual for which the information should have been submitted.
- The legislation is intended to minimize/eliminate situations in which Medicare pays primary for medical expenses when a group health plan (GHP) should be the primary payer for medical services.
- Insurers, TPAs and self-insured/self-administered GHPs are Responsible Reporting Entities (RREs). GHPs are responsible for proper coordination of medical expenses when Medicare is the secondary payer.
- The legislation will, with limited exceptions, apply to employers with more than 20 employees where any employee is covered by a GHP.
- GHP RREs will register on the Coordination of Benefits Secure Web site (COBSW) from April 1, 2009 through April 30, 2009 using a new application designed for this purpose (not currently available). Data will be exchanged on a quarterly basis beginning in July 2009.
- Data required for registration will include RRE Information, Authorized Representative Information, Technical Contact Information, Section 111 File Submission Profile Information, Agent Information and a signed Data Use Agreement.
- The minimum number of Required Data Elements for the monthly data exchange will be twenty three. Items such as Beneficiary Name, Social Security Number, Date of Birth, Coverage Type, Policy Number, Employee Employment Status and Employer EIN are mandated.
- GHPs can receive a value in return while complying with the MMSEA mandate by including data for their inactive populations (retirees).
For additional information related to MMSEA, refer to the following documents:
Mandates like the MMSEA place additional burdens on organizations without providing any returns. Having to comply with these mandates detracts from an organizations core business and diverts scarce resources needed to keep you successful in tight economic times. SSDC's expertise in data transfers with CMS can assist your organization in meeting the MMSEA mandate quickly and economically. Our experience and technology goes beyond simple software that maps or formats data. SSDC allows organizations to meet the MMSEA reporting requirement without creating a new system or dedicating valuable internal resources and does so at a low cost.
To learn how SSDC can assist you in complying with the MMSEA requirements as an agent. Please contact email@example.com
Omnibus Budget Reconciliation Act (OBRA)
On August 10, 1993, Medicare became primary for disabled individuals with the passage of OBRA 1993. Insurance primacy was now based on “current employment status.” This change meant that if an individual had health insurance coverage due to someone’s employment status (his/her own or a family member’s), the Large Group Health Plan would be primary. However, if coverage was due to disability or retirement, Medicare would be primary. For more specifics on OBRA, refer to OBRA 1993 Regulation.pdf.
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and associated privacy regulations (45 CFR Parts 160 and 164— “the Privacy Rule”) require “covered entities” (health plans, health care clearinghouses and health care providers) to protect the privacy of individually identifiable health information from unauthorized use and disclosure and to comply with security standards designed to safeguard the confidentiality and integrity of protected health information. HIPAA also establishes uniform standards for the electronic exchange of health care data. For more specifics HIPAA, refer to HIPAA Privacy Summary.pdf.