American Hospital Association Urges CMS To Extend Enforcement Discretion For No Surprises Act

3.2% payment increase is not enough, American Hospital Association says |  Healthcare Finance NewsSource: Healthcare Finance, by Jeff Lagasse

The American Hospital Association has urged the Centers for Medicare and Medicaid Services to extend enforcement discretion for the No Surprises Act regulatory requirement that healthcare providers exchange certain information to create a good faith estimate for uninsured and self-pay patients – until the agency identifies, and providers can implement, a standard, automated way to exchange the information.

“In the interim final rule implementing this policy, CMS notes that it is exercising enforcement discretion until Jan. 1, 2023, as it may take time for providers and facilities to ‘develop systems and processes for receiving and providing the required information,’” AHA wrote. “We agree that developing and implementing the solution will take time and cannot be achieved efficiently without additional guidance from CMS that identifies a standard technical solution that can be implemented by all providers.”

One of the main concerns from the AHA is that there are currently no methods for unaffiliated providers to share or receive good faith estimates with a convening provider or facility in an automated manner. To share this information, billing systems would need to be able to request and transmit billing rates, discounts and other necessary information for the good faith estimates between providers/facilities.

This is not something that practice management systems can generally do, said the AHA, since billing information is traditionally sent to health insurers and clearinghouses, not other providers.

“Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors,” the AHA wrote.

AHA requested an extension in enforcement discretion until a technical solution has been found and implemented.


Without an automated standard, the AHA said, providers would need to determine individually how to transmit the information. That in turn could lead to variance throughout the industry, especially considering differences in size and technical sophistication among co-providers and facilities. Navigating a non-standardized process, the AHA contended, would increase administrative burden on providers.

To help work toward a standard solution, The AHA said it’s partnering with the American Medical Association, the Medical Group Management Association and HL7 to create a workgroup to discuss potential technical solutions for sharing and receiving critical information among providers. The group will consist of providers and vendors with knowledge of provider systems.


In December 2021, the American Hospital Association, American Medical Association and other provider organizations sued the Department of Health and Human Services and other federal agencies over implementation of the No Surprise Act. The groups are not against the legislation, they said in the lawsuit filed in federal court but take issue with how HHS implemented a dispute resolution process in the bill.

The No Surprises Act prevented 2 million surprise bills for the commercially insured, according to a survey by AHIP and the Blue Cross Blue Shield Association released in May. The analysis further showed that, if the trend continues, more than 12 million surprise bills would be avoided in 2022.

Final Rule on Excepted Benefits

Final Rule On Excepted Benefits

The U.S. Departments of Labor, Health and Human Services, and the Treasury published a final rule to amend the definition of benefits under the Affordable Care Act (ACA). Generally, excepted benefits are not subject to the ban on dollar coverage limits or pre-existing conditions clauses in the ACA. These non-medical benefits offer medical coverage, such as auto liability, workers’ compensation, dental, vision, and long-term care. Employees who only get excepted benefits by their employers can still get premium tax credits to purchase individual coverage through the ACA’s public exchanges. In limited circumstance, the final rules permit group health plan sponsors to offer wraparound coverage to employees who are purchasing individual health insurance in the private market, including in the Health Insurance Marketplace.

The rule sets forth two pilot programs for limited wraparound coverage. One pilot allows wraparound benefits only for multi-state plans in the Health Insurance Marketplace. The other allows wraparound benefits for part-time workers who enroll in an individual health insurance policy or in Basic Health Plan coverage for low-income individuals established under the Affordable Care Act. These workers could, under existing excepted benefit rules, qualify for a flexible spending arrangement alternative to this wraparound coverage.

CMS Issues Medicare Part D Final Rule

The Centers for Medicare & Medicaid Services (CMS) issued final regulations (CMS-4159-F) for the Medicare Advantage and prescription drug benefit (Part D) programs. “The policies finalized in this regulation will strengthen Medicare by providing better protections and improving health care quality for beneficiaries participating in Medicare health and drug plans. The final rule will give CMS new and enhanced tools in combating fraud and abuse in the Medicare Part D program so that we can continue to protect beneficiaries and taxpayers,” Marilyn Tavenner, CMS administrator.
The following are key final provisions:

• Requiring Part D prescribers to enroll in Medicare: CMS is requiring that physicians and eligible professionals who prescribe covered Part D drugs be enrolled in Medicare, or have a valid record of opting out of Medicare, in order for their prescriptions to be covered under Part D. Requiring prescribers to enroll in Medicare would help CMS ensure that Part D drugs are only prescribed by qualified individuals. The final rule allows more time – until June 1, 2015 – for implementation.

• Revoking Medicare enrollment for abusive prescribing practices and patterns: CMS will have the authority to revoke a physician or eligible professional’s Medicare enrollment if CMS determines that he or she has a pattern or practice of prescribing that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements. CMS will also be able to revoke a physician or eligible professional’s Medicare enrollment if his or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked, or if the applicable licensing or administrative body for any state in which he or she practices suspends or revokes his or her ability to prescribe drugs.

• Expanding prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness.

• Broadening the release of privacy-protected Part D data: CMS will expand the release of unencrypted, prescriber, plan and pharmacy identifiers contained in prescription drug event records to give the public broader access to health care data pursuant to CMS’ policies and procedures for release of such data while still preserving the privacy of Medicare beneficiaries.

To view a fact sheet on the final 2015 Part C and D rule, please visit:

HHS issues final rules for applying ACA tax credits and subsidies

HHS issued final rules for health insurance exchanges, including rules for advance payments of premium tax credits, reduced cost-sharing for lower-income enrollees and premium stabilization programs. The rules establish time frames for issuing refunds if advance payments of premium tax credits or cost-sharing reductions are incorrectly applied, or if an enrollee is incorrectly assigned to a standard plan without cost-sharing reductions. The rules also cover oversight of insurers and state exchanges. Modern Healthcare (free registration) (10/24)

IRS issues final ACA rules for individual coverage, penalties

Individuals who do not have health insurance will be subject to an annual penalty of $95 or 1% of income next year, depending on which is greater, rising to $695 or 2.5% by 2016, under final Internal Revenue Service rules. Employees who get health insurance coverage through a union or temporary staffing agency will not be penalized, tax lawyers said. Early retirees, former employees and dependents who are eligible for but decline to purchase coverage through a former employer may be eligible for tax credits if they buy a plan through a public marketplace. Reuters (8/27) , Business Insurance (tiered subscription model) (8/27) , Kaiser Health News/Capsules blog (8/27)

Employees of Religious Organizations Will Get Contraception Coverage

Under Final rules issued by the Administration, non-profit religious organizations will not have to contract, arrange, pay for or refer contraceptive coverage directly. However, no-cost coverage will be provided separately to women who have enrolled in their health plans.

With an insured health plan, the non-profit religious organization can notify its insurer that it objects to offering contraception coverage employees.  The insurer would then notify plan enrollees that it is providing them separate no-cost payments for contraceptive services.

With a self-insured health plans, the non-profit religious organization can notify its third party administrator (TPA) that it objects to contraception coverage. The TPA would then notify health plan enrollees that it is providing or arranging separate no-cost payments for contraceptive services. The final rules are available here:

HHS Issues Final Rule on Essential Benefits

The Dept. of Health and Human Services (HHS) issued a final rule that implements five key consumer protections from the Affordable Care Act:
• Guaranteed Availability – Nearly all health insurance companies offering coverage to individuals and employers must sell health insurance policies to all consumers. No one can be denied health insurance because of a current or previous illness.
• Fair Health Insurance Premiums – Health insurance companies that offer coverage to individuals and small employers will only be allowed to vary premiums based on age, tobacco use, family size, and geography. Factors that are no longer permitted in 2014 include health status, past insurance claims, gender, occupation, how long an individual has held a policy, or size of the small employer.
• Guaranteed Renewability – Health insurance companies will no longer be able to refuse to renew coverage because an individual or an employee has become sick.
• Single Risk Pool – Health insurance companies will no longer be able to charge higher premiums by moving higher-cost enrollees into separate risk pools.  Insurers must maintain a single statewide risk pool for the individual market and single statewide risk pool for the small group market.
 Catastrophic Plans – Young adults and people for whom coverage would otherwise be unaffordable will have access to a catastrophic plan in the individual market. Catastrophic plans will generally  have lower premiums, protect against high out-of-pocket costs, and cover recommended preventive services without cost sharing.

For more information visit:

America’s Health Insurance Plans (AHIP) issued a statement warning that the imposition of richer benefit packages will result in less affordable coverage for small employers, individuals and families by forcing them to buy up to coverage they may not want or need. AHIP noted that Jonathan Gruber, a prominent health economist and policy expert, says that a 10% rise in the cost of the Essential Health Benefits package would increase the federal government’s cost by 14.5%, or $67 billion, and reduce the rate of the insured by 4.5%, or 1.5 million, through 2019.

Many state departments of insurance and state exchange boards have begun requesting formal actuarial and economic forecasts of the effect of the ACA insurance reforms on their state. These independent studies have found that some provisions, including the Essential-Health Benefits and actuarial value requirements, will result in higher premiums.

AHIP is also concerned that the ACA requires the HHS Secretary to ensure that benefits under the Essential Health Benefits package be equal to what’s provided under a “typical employer plan.” While the term “typical employer plan” is not explicitly defined in the statute, it is vitally important for the benefit package be comparable to benefits purchased by small employers since small businesses and individuals will be the primary customers of exchange plan coverage.

AHIP notes that research has shown that workers and families who get health insurance coverage in the individual and small group markets are especially price sensitive. They tend to pay a larger share of the premium. A benefit package that’s modeled after coverage offered by very large employers would significantly increase premiums for small employers and families, thereby making coverage less affordable.

Under the ACA, most individuals will be required to have insurance at least equal to the “bronze” level of coverage. There is evidence to suggest that the minimum actuarial value of 60% may exceed the average value of a policy in a state’s market, particularly for individually purchased plans. For example, the non-partisan Congressional Budget Office (CBO) estimates that the average actuarial value of health insurance in the individual market ranges from 55%to 60%.

Also, researchers have found that the average actuarial value for non-group policies purchased in California was 55% (with a range of 32% to 85%. The California Healthcare Foundation has found that 62% of the 32 individual market plans available in Los Angeles County had actuarial values below the 60% minimum required under the ACA.

AHIP says that lowering the actuarial value for bronze coverage to 55% or 50% could help avoid disruptions in coverage and ensure that premiums stay affordable, especially for price-sensitive, younger individuals who get coverage in the non-group market. Also, policies that help ensure that younger, healthier subscribers remain in the marketplace can help promote a more stable risk pool and make coverage more affordable for everyone.

The ACA establishes limits on deductibles for health insurance plans in the small group market at $2,000 for individuals and $4,000 for families—effective January 1, 2014. In order to meet these new limits, many small group plans, particularly high-deductible/HSA plans, would have to lower deductibles substantially, thereby increasing the cost of coverage. By requiring many plans to lower deductibles, these caps could price many small employers out of the market and limit access to affordable coverage options for small business workers and their families. These caps could be especially problematic for small business employees who enroll in high-deductible/HSA plans—where the average deductible for single coverage ($2,814 in 2010) already exceeds the ACA limits. Eliminating these caps on deductibles can help ensure that affordable health insurance options are available to workers and their families and that small businesses can continue to offer coverage to their employees.

The ACA states that the HHS Secretary “may” include the amount of the annual employer HSA contributions toward the actuarial value calculation. However, in a bulletin issued in February 2012, HHS declared its intention to only include a portion of employer HSA contributions when determining actuarial value. AHIP says that including employer HSA contributions in the actuarial value calculation significantly increases the likelihood that HSA plans will be able to meet the minimum requirement and will help ensure that consumers continue to have access to high-quality, affordable coverage.

AHIP notes that total enrollment in HSA/HDHPs has grown to 13.5 million people (increasing by 2.2 million over the past year alone). Counting all employer contributions toward the HSA/HDHP actuarial value would help ensure that these affordable products remain available to businesses and their workers.

AHIP offers the following recommendations:
• Make the scope of the Essential Health Benefits comparable to the scope of benefits provided under a typical plan purchased by small businesses.
• Lower the minimum actuarial value for health insurance coverage under the ACA to ensure availability of affordable health insurance options and avoid disruptions in coverage.
• Eliminate caps on deductibles in the small group market to ensure affordability of coverage for small businesses and families.
• Require that all employer contributions toward employees’ health savings accounts (HSAs) are considered when determining a plan’s actuarial value.

For more information, visit

Last Updated 06/29/2022

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