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The Wagner Law Group Description 

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 


Established in 1996, The Wagner Law Group has 22 attorneys engaged exclusively in employee benefits, estate planning and employment law. Five of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.



Contact Info

The Wagner Law Group


Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110

Florida Office 

Tel: (561) 293-3590
Fax: (561) 293-3591
7121 Fairway Drive
Suite 203
Palm Beach Gardens, FL 33418


San Francisco Office

Tel: (415) 625-0002

Fax: (415) 829-4385

315 Montgomery Street

Suite 902

San Francisco, CA 94104





December 13, 2012 

 State and Federal Law Alert


CMS Issues Guidance Implementing PPACA's Health Insurance Market Reforms


The Centers for Medicare & Medicaid Services ("CMS") has issued proposed regulations that implement several key health insurance market reforms mandated under the Patient Protection and Affordable Care Act ("PPACA"). In particular, the guidance includes the following provisions:


Guaranteed Availability of Coverage. Health insurance issuers must begin to make coverage available to any individual or employer in the state, with limited exceptions. Thus, health insurance issuers will no longer be able to deny coverage because of a pre-existing condition, past medical claims or potential risk. Furthermore, health insurance issuers will only be able to limit enrollment due to (i) limited open enrollment periods; and (ii) employees living outside the service area of a network plan. The proposed regulations also provide individuals with new special enrollment opportunities in the individual market after loss of other coverage.


Fair Health Insurance Premiums. Health insurance issuers in the individual and small employer markets will only be allowed to vary premiums based on: age (with a maximum 3:1 ratio for adults); tobacco use (with a 1.5:1 maximum ratio and subject to wellness program requirements in the small group market); family size; and geography. Other factors-such as pre-existing conditions, health status, claims history, duration of coverage, gender, occupation, employer size and industry-can no longer be used to increase premium rates. States may adopt more stringent consumer protection laws that go beyond these minimum standards.


Single Risk Pool. Health insurance issuers will be required to maintain a single statewide risk pool for their individual market and one for their small group market. A state may choose to merge these two pools into one. Premiums and annual rate changes would be based on the experience of the entire pool. This particular provision prevents insurers from using separate insurance pools within markets to avoid PPACA's market reforms.


Guaranteed Renewability of Coverage. The proposed regulations reaffirm protections already in effect under PPACA regarding coverage renewal. For example, health insurance issuers cannot refuse to renew coverage because an individual becomes sick or has a pre-existing condition. The proposed regulations also include additional provisions that protect consumers' rights to renew coverage, and increase coverage choices for small employers.


Catastrophic Plans. The proposed regulations outline the standards for enrollment in catastrophic plans. Catastrophic plans are offered only in the individual market. They cover required preventive services without cost sharing, but offer affordable coverage options to young adults and individuals who would otherwise be unable to afford insurance coverage.


The final regulations are scheduled to become effective for plan and policy years beginning on or after January 1, 2014.


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Pursuant to Internal Revenue Service Circular 230, we hereby inform you that any advice set forth herein with respect to US federal tax issues is not intended or written by The Wagner Law Group to be used and cannot be used, by you or any taxpayer, for the purpose of avoiding penalties that may be imposed on you or any other person under the Internal Revenue Code.


This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.