Weekend update

Congress is not in session this week. The current Medicare Part B doctor payment fix expires two weeks from tomorrow. As the FEHBlog has noted there is a bipartisan approach to replacing the sustainable rate of growth formula but no agreement on how to pay for that change. According to Modern Healthcare, The House passed the bipartisan approach but decided to pay for it by waiving the ACA’s individual mandate until 2019. Of course, that approach is unacceptable to the Administration and the Senate leadership. It increasingly looks the can will be kicked down the road until the lame duck session after the mid-term elections.

On Friday, CMS issued guidance that it’s illegal under the ACA for an insurer offering non-grandfathered group or individual health insurance coverage to extend coverage to opposite sex but to not same sex spouses. The guidance, which is based on 45 C.F.R. § 147.104,

does not require a group health plan (or group health insurance coverage provided in connection with such plan) to provide coverage that is inconsistent with the terms of eligibility for coverage under the plan, or otherwise interfere with the ability of a plan sponsor to define dependent spouse for purposes of eligibility for coverage under the plan. Instead, this section prohibits an issuer from choosing to decline to offer to a plan sponsor (or individual in the individual market) the option to cover same-sex spouses under the coverage on the same terms and conditions as opposite sex-spouses. 

Of course, this is not an issue for the FEHBP.  In the FEHBlog’s opinion, a plan sponsor is just asking for trouble if it excludes same sex spouses.

Reuters is reporting that

Aetna Inc, the third largest U.S. health insurer, said on Friday it would not proceed with a proposed $120 million settlement with healthcare providers and plan members over out-of-network reimbursements. Aetna, which had agreed to settle in December 2012, said enough claimants had opted out to trigger a provision enabling it to cancel the deal.

The FEHBlog is saddened this insane litigation continues to plague health insurers. For decades, plans based out of network provider payments on “usual, reasonable, and customary” data compiled by a third party — first a trade association and later an information company affiliated with United Healthcare. The American Medical Association alleged an unholy conflict of interest between United and its affiliate and challenged the integrity of the data . Insurer got caught in the middle in this sort of litigation. Insurers used the data as a common yardstick based on convenience not necessarily accuracy. The phrase “usual reasonable and customary,” however, implied accuracy, and plaintiffs’ attorneys flogged the United affiliate with alleged data flaws. Since this issue arose over 10 years ago — it erupted in late 2008 — plans have dropped the usual, reasonable, and customer phrase in favor of the much more generic plan allowance phrase.  United’s affiliate transferred the data base to a new New York non-profit called Fair Health.  Plans also have switched to Medicare’s relative value schedule as a yardstick. (The SGR controversy concerns setting the dollar multiplier that is multiplied times the Medicare relative value to obtain the payment value.) he incident does illustrate the importance of clear plan language.

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