By Cynthia Marcotte Stamer

The Departments of Treasury (IRS), Labor (DOL) and Health & Human Services (HHS) are inviting public comments on impending new federal requirements that will compel health insurance issuers offering individual or group medical coverage to send annual reports to HHS on the percentages of premiums that the coverage spends on  reimbursement for clinical services and activities that improve health  care quality, and to provide rebates to enrollees if this spending does  not meet minimum standards for a given plan year added as Section 2718  of the Public Health Service Act (PHS Act), by the Patient Protection and Affordable Care Act  (PPACA), Public Law 111-148, enacted on March 23, 2010.

Among other things, Section 2718 of  the PHS Act, Section 715 of the Employee Retirement Income Security Act  of 1974 (ERISA) and Section 9815 of the Internal Revenue Code of 1986  (the Code) will require  health  insurance issuers offering group or individual  coverage to report to HHS annually:

• The ratio of the incurred loss (or incurred claims) plus the  loss adjustment expense (or change in contract reserves) to earned  premiums (also known as the medical loss ratio (MLR)); and
• The percentage of total premium revenue–after accounting for collections or receipts for risk  adjustment and risk corridors and payments of reinsurance–that the  coverage spends: (1) on reimbursement for clinical services provided to enrollees; (2) for activities that improve health care quality;  and (3) on all other non-claims costs, including an explanation of the  nature of these costs, and excluding Federal and State taxes and  licensing or regulatory fees.

PPACA also requires that HHS make these reports available to the public on the Internet Web site of HHS.  To review the request for comments and its instructions for commenting on the new requirements, see here.

For Assistance With This Opportunity Or Other Health Industry Concerns

If your organization needs advice or help with commenting on the request for comments or to evaluate or respond to other health care reform regulations or other health care matters, contact Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here. 

Vice President of the North Texas Health Care Compliance Professionals Association, Exempt Organization Vice-Coordinator of the Southern States IRS TEGE Council, Chair of the American Bar Association (ABA) Real Property, Probate & Trust Section Employee Benefits & Other Compensation Arrangements Group, a Council Member of the ABA Joint Committee On Employee Benefits Council, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 22 years experience advising health industry clients about these and other matters.    A popular lecturer and widely published author on health industry matters, Ms. Stamer advises hospitals and other health industry clients about responding to and using these and other quality measures and other related concerns.  Ms. Stamer also publishes and speaks extensively on health and managed care industry quality, regulatory, reimbursement, and other operations, risk management and public policy concerns.  Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.  For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.  

Other Recent Developments & Resources

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

• NLRB Orders Union Elections In 31 California Health Care Facilities To Proceed
• IRS To Allow Medical Resident FICA Refund Claims
• Stamer Speaks To Chiefs of Staff About JCAHO Physician Performance Evaluation Requirements
• HIPAA Heats Up: HITECH Act Changes Take Effect & OCR Begins Posting Names, Other Details Of Unsecured PHI Breach Reports On Website
• HHS Delays 2010 HHS Federal Poverty Rate Update To March 1, 2010
• Rising Enforcement and Changing Rules Require Prompt Review & Update of Health Plan Privacy & Data Security Policies & Procedures
• Pfizer To Pay $2.3 Billion For Fraudulent Marketing In Largest DOJ Health Care Fraud Settlement
• Maximum Penalty For Patient Protection Act Confidentiality Breaches To Rise To $11,000
• HHS Delays 2010 HHS Federal Poverty Rate Update To March 1, 2010
• OIG Special Fraud Alert Targets DME Telemarketing
• Federal HEAT & Other Federal Health Care Fraud Efforts Score More Than 15 Successes As OIG Claims $20.97 Billion Saved From Enforcement Activities In December
• HEAT Initiative Snares Health Fraud Related Guilty Pleas of Physical Therapist, Money Launderer and Patient Recruiter In Detroit
• Medicare Paid Physicians More Than $92 Million in Incentives for 2008 Under the Physician Quality Reporting Initiative
• Renal Dialysis Faculties Encouraged to Review Current Protocols for Administering Erthropoiesis-Stimulating Agents
• CMS Publishes Updated FY 2010 Inpatient Rehabilitation Facility Prospective Payment System Final Rule
• Retaliation For Filing HIPAA Complaint Recognized As Basis For State Retaliatory Discharge Claim
• Quest Diagnostics Inc. To Pay $688,000 In Overtime Back Wages Settlement After Misclassifying Systems Employees As Exempt
• Homecare Workers Exempt From FLSA

For More Information

We hope that this information is useful to you.  If you need assistance with auditing or defending these or other health care compliance, risk management, transaction or operation concerns, please contact Cynthia Marcotte Stamer, at (469) 767-8872 or to cstamer@solutionslawyer.net.. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other internal controls and risk management matters. 

You can review other recent health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here.  If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information to here.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here.  To unsubscribe, e-mail here.

©2010 Cynthia Marcotte Stamer.  All rights reserved.

This entry was posted on Thursday, April 15th, 2010 at 5:32 am and is filed under Health Care, Health Care Finance, Health Care Quality, Health Care Reform, Health Insurance Exchange, Health Plan, Health Plans, Medicare Advantage. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.