Understanding Opportunities and Pitfalls When Contracting with ACA Exchange Qualifi ed Health Plans

April 30, 2014 10:00am

Robert J. Hill
Partner
Reed Smith LLP

• Exchange Qualifi ed Health Plan (QHP) Fundamentals
– Essential Health Benefi t formulary requirements
– QHP Premiums and Premium Tax Credits
– Cost-Sharing Subsidies, Risk Adjustment, Reinsurance and Risk Corridors
• QHP Marketplace and Enrollment
– Real-world example of plan comparison and enrollment
– Who is enrolling? In what plans?
• Fraud and Abuse Issues
– Are QHPs subject to the Anti-Kickback Statute? False Claims Act?
 Sebelius letter and subsequent developments
– Implications for Manufacturer/Provider Coupons, Copay Assistance, Premium Assistance
• Rebate Contracting for QHPs
– Tailoring Rebate Terms/Conditions for QHPs
– Legal Reporting/Disclosure issues; PBM Administrative Fees
– Utilization Data requirements
• Technical/Implementation Issues – 2014 and beyond
– “Back-end” systems; SHOPs
– Enrollment fraud?
– Latest developments