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Effective March 23, 2011, requires that community mental health centers (CMHCs) that provide Medicare partial hospitalization services provide at least 40% of its services to non-Medicare covered beneficiaries. Further delineates that such services are those other than the services provided in an individual’s home or in an inpatient or residential setting.
In a February 2011 final rule with comment addressing a number of new ACA-authorized provider screening and enrollment provisions, CMS noted that while this particular provision was outside the scope of the rule CMHCs were assigned to the “moderate screening level.”
In June 2011, CMS issued a proposed rule (but, as of the date of writing, had yet to finalize) that would establish Medicare conditions of participation (CoPs) for CMHCs (see here and here). Furthermore, the application of the partial hospitalization payment (PHP) policy was also discussed in the CY 2011 OPPS/ASC final rule, followed by further clarifications in the CY 2012 OPPS/ASC final rule with comment and the CY 2012 OPPS/ASC final rule.
SEC. 1301 ø42 U.S.C. 18021¿. QUALIFIED HEALTH PLAN DEFINED. (a) QUALIFIED HEALTH PLAN.—In this title: (1) IN GENERAL.—The term ‘‘qualified health plan’’ means a health plan that— (A) has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in section 1311(c) issued or recognized by each Exchange through which such plan is offered; (B) provides the essential health benefits package described in section 1302(a); and (C) is offered by a health insurance issuer that— (i) is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title; (ii) agrees to offer at least one qualified health plan in the silver level and at least one plan in the gold level in each such Exchange; (iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange or whether the plan is offered directly from the issuer or through an agent; and (iv) complies with the regulations developed by the Secretary under section 1311(d) and such other requirements as an applicable Exchange may establish. øParagraphs (2)-(4) substituted for previous paragraph (2) by section 10104(a)¿ (2) INCLUSION OF CO-OP PLANS AND MULTI-STATE QUALIFIED HEALTH PLANS.—Any reference in this title to a qualified health plan shall be deemed to include a qualified health plan offered through the CO-OP program under section 1322, and a multi-State plan under section 1334, unless specifically provided for otherwise. (3) TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MED- ICAL HOME PLANS.—The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan. (4) VARIATION BASED ON RATING AREA.—A qualified health plan, including a multi-State qualified health plan, may as appropriate vary premiums by rating area (as defined in section 2701(a)(2) of the Public Health Service Act). (b) TERMS RELATING TO HEALTH PLANS.—In this title: (1) HEALTH PLAN.— (A) IN GENERAL.—The term ‘‘health plan’’ means health insurance coverage and a group health plan. (B) EXCEPTION FOR SELF-INSURED PLANS AND MEWAS.— Except to the extent specifically provided by this title, the term ‘‘health plan’’ shall not include a group health plan or multiple employer welfare arrangement to the extent the plan or arrangement is not subject to State insurance regulation under section 514 of the Employee Retirement Income Security Act of 1974. (2) HEALTH INSURANCE COVERAGE AND ISSUER.—The terms ‘‘health insurance coverage’’ and ‘‘health insurance issuer’’ have the meanings given such terms by section 2791(b) of the Public Health Service Act. (3) GROUP HEALTH PLAN.—The term ‘‘group health plan’’ has the meaning given such term by section 2791(a) of the Public Health Service Act.
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