CMS Releases Final 2017 Letter To Issuers In The Federally Facilitated Marketplaces

On February 29, 2016, the Centers for Medicare and Medicaid Services (CMS) released its final 2017 Letter to Issuers in the Federally Facilitated Marketplaces. This finalizes the draft 2017 Letter to Issuers CMS released on December 23, 2015. This post examines the final letter to FFM issuers and ends with a brief discussion of two new court decisions rejecting challenges to the Affordable Care Act.

The Letter To Issuers

CMS issues a letter to FFM insurers every spring at about the time when it releases its final benefit and payment parameters rule (the "payment rule"). (See earlier posts on the highlights of the payment rule and letter to FFM issuers and on the details of the payment rule, part 1 and part 2). The issuer letter governs health plans in the federal marketplace for the next year, in this case 2017. It provides guidance for insurers as they formulate their health plans offerings for the plan year.

Much of the letter to issuers is process oriented; it tells insurers what information they have to file where and when. Other sections of the letter largely repeat information found in the payment rule; it also contains much material found in earlier annual letters to issuers as the operation of the marketplaces become more and more routine. But other sections of the letter lay out in greater detail new initiatives identified in the payment rule. In the case of the 2017 letter, provisions on standardized plans, network adequacy, discriminatory benefit design, and formulary review are of particular interest.

Application Of The Letter

The letter applies to insurers that offer qualified health plans (QHPs) and standalone dental plans (SADPs) in the FFM and federally facilitated Small Business Health Options Program (SHOP) exchange. It applies (although with some differences) in all states that use the FFM platform, including states in which the federal government enforces the Affordable Care Act directly; states in which the state enforces general ACA provisions but the federal government performs all marketplace functions; plan-management FFM states in which the state performs plan management functions and makes plan certification recommendations to CMS; and states in which the state-based marketplace uses the FFM platform for eligibility and enrollment functions.

In states other than direct enforcement states, CMS relies on state review of policy forms and rate filings for determining compliance with market-wide standards. States with effective rate review programs also bear primary responsibility for reviewing rates, while states with plan management authority must make timely recommendations as to QHP certification. In direct enforcement states (Alabama, Texas, Oklahoma, Missouri, and Wyoming), insurers must submit their rates and forms to CMS for review.

States performing QHP certification reviews may exercise reasonable flexibility in their application of CMS' QHP certification guidelines as long as their application of each standard is consistent with CMS regulations and guidance. CMS will review state certification recommendations to ensure that they are consistent with federal guidelines. Multistate plan insurers must also be approved by the Office of Personnel Management. The FFM only offers QHPs and SADPs and will not display ancillary insurance products or plans that are not QHPs.

Qualified Health Plan Certification And Rate Filing Calendar

QHP insurers must submit applications and rate filings for 2017 certification between April 11 and May 11, 2016. Applications will not be accepted after this date. CMS begins an exchange of correction notices and revised data with insurers on June 15.

QHP insurers will be able to view plan data in the Plan Preview environment to identify and correct submission errors. After May 11, plans will not be able to change plan type and must petition CMS to change service areas, but can make other changes before August 23. Final submission of all QHP data and permitted changes are due to CMS on August 23. After this date, insurers are only permitted to make limited corrections having to do with data displays or with aligning QHP data with products and plans approved by a state with permission from CMS. Insurers also, however, have a final opportunity to withdraw plans.

States will send their final plan recommendations to CMS by September 8 and CMS will send certification notices to insurers on September 15 or 16 confirming all approved plans. Insurers must then submit signed certification agreements to CMS. The letter describes in detail how exchanges of information are to be handled. Insurers who miss deadlines or file inaccurate information can have their applications denied.

Insurers seeking to offer QHPs or SADPs in the FFM must submit their application through the federal Health Insurance Oversight System (HIOS) by May 11. In plan management states, QHP applications are submitted through the National Association of Insurance Commissioners (NAIC) System for Electronic Rate and Form Filing (SERFF) system in accordance with timelines and processes prescribed by the states. The plan management states will transfer the data submitted by insurers to CMS.

Insurers seeking to offer QHPs through the FFM must also submit a Unified Rate Review Template (URRT) to HIOS. In states with effective rate review programs, insurers must submit proposed rate filings for non-grandfathered individual and small group coverage (QHP and non QHP) to the state on a date set by the state, but no later than July 15, 2016.

Insurers offering QHPs and SADPs in the FFM must between September 19 and 23 submit a final list of QHPs and SADPs that they intend to offer for the 2017 open enrollment period. They must sign and submit to CMS a QHP Certification Agreement and Privacy and Security Agreement, with a Senior Officer Acknowledgment confirming that a senior officer of the insurer has knowledge of the insurer's plans and attestations. CMS will review, sign, and return the agreements by October 4.

Insurers that seek recertification of 2016 plans for 2017 must follow the same process as is prescribed for new plans. Returning insurers must for 2017 (as they did for 2016) submit a crosswalk of their 2016 and 2017 QHPs and SADPs to help the FFM passively reenroll 2016 enrollees into similar plans if they do not return to the marketplace to actively reenroll for 2017. See my post on the payment rule which describes how auto-reenrollment will work for 2017.

Standardized Plans

CMS has announced in the 2017 payment rule that it is giving insurers the option of offering standardized plans beginning in 2017.  Insurers will have the option of offering plans that have standardized in-network deductibles, cost-sharing limits, and copayments and coinsurance amounts for a key set of essential health benefits, as well as four tiers of drug benefits. QHP insurers are encouraged, although not required, to offer at least a standardized silver plan (including silver plan variations for cost-sharing reductions).

Insurers may offer more than one standardized plan at a level of coverage if the plans are meaningfully different. Insurers might, for example, offer additional standardized plans with extra benefits or with varying networks or other features. CMS is conducting consumer testing to determine how best to display standardized plan options. For more information on standardized plans, see my post on the payment rule.

QHP Certification Requirements

To be qualified for certification, QHPs must be licensed and in good standing — that is, without outstanding state sanctions. QHPs must have a service area that covers at least a county, or group of counties, unless the FFM concludes that a smaller service area is necessary, nondiscriminatory, and in the best interest of marketplace enrollees. Service areas must be established without regard to racial, ethnic, language, or health-status related considerations.

Network Adequacy

In the draft payment rule, CMS had proposed that the states would have to adopt quantifiable network adequacy standards or a default time and distance standard would apply. In the final payment rule, CMS backed off of this requirement. CMS notes in the letter to issuers, however, that it will itself apply time and distance standards focusing on primary care, dental (if applicable), endocrinology, infectious diseases, oncology medical/surgical, oncology radiation/radiology, mental health (including substance use disorder treatment), rheumatology, hospitals, and outpatient dialysis. The letter includes a table of maximum time and distance standards. For example, in a large urban area at least 90 percent of enrollees in a plan should be able to reach a hospital in 10 miles or twenty minutes; in a rural area in 60 miles or 75 minutes.

Insurers that cannot meet these standards because of local circumstances may submit a justification for their inability to meet the standard. CMS expects that insurers will be able to meet the standards at least 90 percent of the time and will not need to submit justifications more than 10 percent of the time.

The letter, like the payment rule, provides that insurers should give regular patients at least 30 days notice of termination of provider. Where 30 days notice is not possible, notice should be given as soon as possible. Insurers should work with providers to obtain lists of their patients or use claims data to identify patients of particular providers.

Patients in active treatment for life-threatening or serious acute conditions or in their second or third trimester of pregnancy or postpartum, or for whom a treating physician attests that discontinuance of treatment by the provider would worsen the condition or interfere with anticipated outcomes, must be allowed to continue treatment by providers terminated without cause for up to 90 days or until the treatment is complete. Insurers need only cover treatment until the patient transitions to an in-network provider, exceeds benefit limitations, or no longer needs care. Insurers are only required to pay network rates leaving open the possibility that providers will balance bill.

The letter provides greater detail on CMS's intended development of a network breadth label to guide shoppers on healthcare.gov than is found in the payment rule. This measure will focus on adult primary care, pediatric primary care, and hospitals, with either separate classifications as to each or a composite classification. The classifications will be calculated by comparing the total number of providers available in each of the classifications in a plan's network to the total number of that classification of providers available in all QHPs in a county. This number is called the Provider Participation Rate, or PPR.

All networks within a standard deviation of the median PPR will be labeled as standard. Networks with a PPR more than a standard deviation above the mean will be labeled "broad" and those with a PPR more than a standard deviation below the mean will be labeled "narrow." Based on 2016 data, CMS believes about 68 percent of all plans will be standard, with 16 percent broad and 16 percent narrow.

The draft letter had included a proposal as well for dealing with surprise out-of-network bills in situations where an enrollee uses an in-network provider. CMS has decided not to implement this proposal (which has been dramatically weakened in the 2017 payment rule), and has thus dropped the proposal from the final letter.

Essential Community Providers

The final letter contains a lengthy section addressing coverage of essential community providers (ECP) — providers that serve low-income and medically underserved individuals. The 2017 ECP standards largely repeat those applied in 2016. In general, insurers must have contracts with 30 percent of available ECPs in their service area, offer contracts in good faith to all Indian health providers in their service area, and offer contracts in good faith to at least one ECP in each of six categories of ECPs (family planning providers, federally qualified health centers, hospitals, Indian health care providers, Ryan White providers, and "other" ECPs). Multiple ECPs located at a single address will only count as one ECP for calculating the 30 percent ratio. Further provisions on contracting with Indian health providers are included later in the letter.

CMS has recently published a list of ECPs which includes providers that petitioned to be included on the list and met certain criteria. Insurers can "write in" providers that they wish to include as ECPs in their plans as in prior years, but "write-in" providers will only count toward satisfaction of the 30 percent standard for 2017 if the provider petitions to be listed as an ECP generally no later than August 22, 2016.

Insurers that do not meet the 30 percent standard may submit a narrative justification explaining how they adequately meet the needs of their low-income and medically underserved enrollees and how they intend to increase ECP participation in the future. The final letter describes in detail the information the narrative justification must include.

The letter also describes in detail alternative ECP standards that must be met by plans that provide services through employed or contracted medical groups or hospitals, such as staff model HMOs. It also provides that a SADP must offer good faith provider contracts to at least 30 percent of the dental ECPs and to all available Indian dental health care providers in its service area. As with health insurers, a SADP unable to satisfy the 30 percent requirement may offer a narrative justification meeting specified standards.

QHPs must pay federally qualified health centers Medicaid rates or a negotiated rate that is at least equal to the rates generally paid by the QHP insurer.

Accreditation And Quality Requirements

QHP insurers that will be in their fourth year of FFM participation in 2017 must be accredited based on local performance of their QHPs with respect to nine specific criteria. Insurers in their second and third year of FFM participation must at least be accredited for their commercial or Medicaid products, while insurers in their first year must have at least scheduled or planned to schedule an accreditation review. The letter lists accreditation categories that are acceptable, including "provisional" or "conditional" accreditation.

QHP insurers must verify that hospitals with more than 50 beds with which the insurer contracts have implemented a person-centered discharge program and use a patient safety evaluation system, including a contract with a patient safety organization or an alternative approach described in the letter and in the payment rule. CMS also encourages QHP hospitals to track patient safety events using the AHRQ Common Formats approach.

QHP insurers must collect and submit validated clinical quality measure data during 2016. They must contract with HHS-approved QHP enrollee survey vendors to collect and submit enrollee survey data on their behalf. CMS will use the quality and satisfaction survey data to calculate for the first time, for the 2017 open enrollment period, ratings that will be displayed on the marketplace website for each QHP product type using a five-star scale. QHP insurers may also use their star ratings in their 2017 plan year marketing materials. State-based marketplaces are also required to display QHP quality rating information calculated by CMS for 2017.

Insurers with non-child-only QHP products covering more than 500 enrollees that offered marketplace coverage during 2014 and 2015 must implement a quality improvement strategy (QIS) complying with recently released guidelines. Insurers are expected to submit their QIS plan during the 2016 QHP certification process for implementation in 2017. A QIS offers incentives to providers or enrollees to improve health care quality or outcomes. State Based Marketplaces (SBMs) as well as the FFM must ensure insurer compliance with QIS requirements. In plan management states, the QIS will be reviewed by both the state and the FFM.

Rate Review

Under final letter and the 2017 payment rule, non-grandfathered plans in the individual and small group market must submit the Unified Rate Review Template to CMS covering all their non-grandfathered individual and small group plans, even if they propose no rate change or a rate decrease. They must also submit the template for all new plans. Rate increases would be subject to review if the average rate increase for any plan within a product for all enrollees, weighted by premium volume and applying premium rating factors, is 10 percent or more.

CMS does not intend to duplicate rate reviews carried out by states under state law, but will consider recommendations from state regulators on whether particular insurers should be excluded from the marketplace based on patterns and practices of unjustified rate increases. Information supporting all proposed rate increases, whether or not subject to review, will be posted on the CMS rate filing website, omitting trade secrets and confidential commercial or financial information.

Discriminatory Benefit Design

The final letter contains provisions regarding discriminatory essential health benefit (EHB) and QHP benefit designs. Non-grandfathered health plans in the individual and small group market may not discriminate in the provision of essential heath benefits (EHB) on the basis of age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health condition. Age limits may be considered discriminatory if they are applied to EHB services found to be clinically effective at all ages. Discrimination requirements should not be circumvented by labeling a benefit clinically appropriate for adults as a pediatric service. Placing all drugs that cover a specific condition in the highest-cost formulary tier or refusing to cover a single-tablet or extended release drug product without adequate justification might be discriminatory. Enforcement of the non-discrimination requirement with respect to EHB is largely the responsibility of state regulators, although civil rights laws that apply are also enforced by the Office of Civil Rights of HHS.

CMS will assess compliance of QHPs with nondiscrimination requirements. It will conduct cost-sharing outlier analysis of QHPs to identify outliers based on estimated out-of-pocket costs associated with standard treatment protocols. For 2017, this analysis will address bipolar disorder, diabetes, HIV, rheumatoid arthritis, and schizophrenia. CMS will also review plan benefit information, including information in the "exclusions" or "explanations" sections, to identify reductions in generosity of a benefit for some subsets of individuals that are not based on clinical guidelines, medical evidence, and reasonable medical management.

Drug Formularies

CMS will perform several reviews of drug formularies. First, CMS will perform an outlier analysis comparing plan formularies to formularies at both the state and national level to ensure that QHPs meet outlier threshold levels. QHPs that subject an unusually high number of drugs in a class or category to prior authorization or step therapy would be identified as outliers.

Second, CMS will review each QHP's drug coverage to ensure the availability of drugs to treat—consistent with clinical guidelines—bipolar disorder, breast cancer, diabetes, hepatitis C, HIV, multiple sclerosis, prostate cancer, rheumatoid arthritis, and schizophrenia. It will also review cost-sharing for these drugs to determine whether high cost sharing is being used to discourage enrollees with these conditions. Finally, it will review formularies to identify "adverse tiering" in which drugs to treat certain chronic, high-cost conditions are assigned consistently to high cost-sharing tiers.

Meaningful Difference

CMS will continue to review plans to ensure that they are "meaningfully different" to support consumer choice. CMS will first group together plans that are of the same type, child-only-plan offering status, metal level, and service area. Within these groups, CMS will consider plans meaningfully different only if they have:

• Or do not have an integrated medical and drug maximum-out-of pocket limits,
• Or do not have an integrated medical and drug deductible,
• Multiple-in-network tiers instead of one,
• $200 or more difference in maximum out-of-pocket limits,
• $100 or more difference in deductibles,
• A different provider network with a different network ID,
• Differences in additional benefits that display on the healthcare.gov website, such as acupuncture or bariatric surgery.

Differences in health savings account eligibility or self-only and non self-only offerings do not count as meaningful differences. Differences in formularies do not qualify as meaningful differences. If a plan is flagged as not meaningfully different, an insurer must modify it or provide a justification to CMS.

Third-Party Payments And Cost-Sharing Reductions

The final letter notes that insurers offering QHPs or SADPs are required under the 2017 proposed payment rule to accept third-party payments for premiums or cost sharing from federal or state government programs, including Ryan White HIV/AIDs programs and from their grantees or sub-grantees. Cost sharing payments might in some circumstances be made through an insurer's downstream entity, such as a pharmacy benefit manager operating a mail order pharmacy program.

QHP must offer plans meeting the standard reduced cost-sharing variations for low-income enrollees. The letter contains guidelines to ensure that reduced cost-sharing plans meet the prescribed actuarial value and maximum out-of-pocket limits, and that they under no circumstances provide less generous coverage than higher cost-sharing plan variations. It also describes the 2017 data integrity tool that plans must use and data integrity reviews CMS will conduct.

Decision Support Tools

For the 2017 open enrollment period, CMS will offer again on the FFM the marketplace the provider lookup, formulary lookup, and out-of-pocket cost comparison consumer support tools that it premiered in 2015 for 2016 plans. The final letter sets out the requirements that QHP insurers must meet to make their provider network directories and drug formularies accessible to consumers.

In the FFM, QHP and SADP provider directories and QHP formularies must be provided in machine-readable form to facilitate the provision of data for the lookup tools. Provider directories must be updated at least monthly. Provider directories and formulary drug lists must be viewable on an insurer's website without a consumer having to create or access and account or enter a policy number. QHP insurers must also provide the inputs necessary for the out-of-pocket cost calculator. QHP insurers will also be required to meet transparency reporting requirements once these are finalized.

Standalone Dental Plans

Standalone dental plans are only required to meet a subset of the requirements that apply to QHPs and their application requirements are truncated accordingly. The final letter identifies the requirements that they must meet. In particular, it identifies the requirements that a SADP must meet to be identified as providing child and adult dental care. It also references the payment letter's provisions on SADP annual cost sharing limit updates.

Compliance Issues, Including Agent And Broker Oversight

The final letter contains a substantial chapter dealing with oversight of QHPs and agents and brokers. Each insurer participating in the FFM will be assigned an account manager to serve as its point of contact with CMS. CMS will continue to monitor compliance of QHP insurers with program requirements. The letter reiterates that the good faith compliance policy that applied during the first two years of the marketplaces ends at the conclusion of 2015, and while CMS will continue to help insurers understand program requirements, good faith is no longer a defense to noncompliance. CMS will conduct risk-based and targeted compliance reviews, which may be desk or on-site reviews, and coordinate with state regulatory authorities. .

QHP insurers are responsible for ensuring compliance by their downstream and delegated entities, including agents and brokers. To assist consumers in the FFM and FF-SHOP, agents and brokers must sign general and privacy and security agreements with the FFMs. Web brokers must sign web broker agreements. CMS can terminate these agreements for sufficiently serious noncompliance or material breach. Agents and brokers in the FFM must also comply with FFM standards of conduct finalized in the payment rule.

The 2017 payment rule provides that if CMS reasonably suspects that an agent or broker may have engaged in fraud or abusive conduct that may result in imminent or ongoing consumer harm using personally identifiable information of FFM applicants or enrollees, or in connection with an FFM enrollment, CMS may impose an immediate 90 suspension. Suspended brokers or agents may submit information rebutting the allegations, to which CMS must respond within 30 days. If a state or federal agency determines that an agent or broker has engaged in such conduct, CMS may immediately terminate the agent or brokers FFM agreements. States, of course, retain primary disciplinary authority over agents and brokers, but CMS will notify states of disciplinary action it takes.

The final letter reiterates requirements that apply to web brokers, including oral interpretation requirements in 150 languages. As of 2017, web brokers who have been registered with the FFM for at least a year must provide language taglines on their websites and critical documents for the top 15 languages spoken by limited English proficiency individuals in a relevant state, and translation of website content into any non-English language spoken by at least 10 percent of the population of a state. CMS will publish guidance identifying such languages soon. The letter also outlines future plans for expanded direct enrollment by web-brokers, described more fully in the payment rule, but notes that this functionality will not be available for 2017.

The final letter notes that agents and brokers must be paid the same compensation for the sale of QHPs in the marketplace as for similar plans outside the marketplace and describes how similarity of plans will be judged. It does not address the recent situation where insurers have been refusing to pay commissions to brokers for marketplace products, in particular for special enrollment period enrollees.

The letter also describes how brokers and agents are identified for enrollments, including passive reenrollments. It suggests that insurers should withhold commissions from brokers and agents who fail to register or otherwise fail to comply with federal requirements. Finally, it describes the program under which HHS-approved vendors offer training to agents and brokers for assisting consumers on the FFM.

CMS has authority to monitor QHP marketing practices, including ensuring that QHP insurers do not discriminate based on race, color, national origin, disability, age, sex, gender identity, or sexual orientation. Marketing materials and information provided by agents and brokers must also be accurate and not misleading. The use of the terms "exchange" or "marketplace" in websites might be considered misleading.

The Federally Facilitated SHOP

The final letter examines in some detail how employer and employee renewals and non-renewals and enrollment reconciliations are handled in the FF-SHOP. This information will not be examined here. The letter notes that CMS will not have the operational capacity for 2017 to support calculating premiums based on average enrollee premium amounts. It will also not be able to automatically renew SHOP enrollments. Personalized notices will be sent to employers approximately two months before the end of the employer's current coverage to remind the employer to renew.  Qualified employers renewing SHOP coverage must give their employees an open enrollment period of at least one week.

Consumer Support And Meaningful Access

The final letter next deals with consumer support and related issues. It describes how "cases" involving consumer issues are handled in the FFM, as well as the responsibilities of QHP insurers for helping to resolve cases. The letter notes that although cases usually involve specific identified consumers, CMS intends to address complaints that it receives about machine readable provider or formulary data on an anonymous basis as the identity of the complaint is not relevant to resolving these issues.

The letter addresses meaningful access requirements for non-English speakers established by the 2016 payment rule. These include oral translation in 150 languages. Beginning as of the first day of open enrollment in the individual market for 2017, taglines must be provided on website content and on critical documents indicating the availability of language services in the top 15 languages spoken by people with limited English proficiency in the state. The letter lists ten categories of documents that are considered critical. Website content must be translated into languages spoken by at least 10 percent of residents with limited English proficiency.

QHP insurers are required to provide summaries of benefits and coverage compliant with federal requirements. SBCs must include a web address where a copy of the individual coverage policy or group certificate of coverage may be found. QHP SBCs must disclose whether or not the QHP pays for abortions for which federal funding is not available. QHP insurers are required to make SBCs available that accurately reflect each cost-sharing plan variation. Insurers must provide an appropriate SBC for a plan variation within seven days after receiving notice that a marketplace has assigned an enrollee to a new plan variation. A draft SBC template has just been released by HHS, but will not be in place for 2017 plans.

Finally, the letter concludes with sections addressing tribal relations and services and the responsibilities of the new state-based marketplaces using the FFM (SBM-FM) for certain functions. While the state-based marketplace retains primary responsibility for enforcing QHP requirements, the FFM can suppress plans in these states that do not comply with program requirements to ensure that consumers only have access to compliant plans. SBM-FMs are discussed at greater length in the payment rule.

Two Courts Rule On Two Cases Involving ACA Implementation

Two courts have recently decided cases involving the implementation of the ACA. First, on March 1, 2016, Judge Frank A. Pfiffner, a Superior Court judge in Anchorage, upheld the decision of Alaska's governor Walker to expand Medicaid in Alaska Legislative Council v. Walker.

Alaskan law makes all individuals eligible for Medicaid "for whom the Social Security Act requires Medicaid coverage." The ACA adds to the categories of persons for whom the Medicaid statute mandates Medicaid coverage individuals with household modified adjusted gross incomes below 133 percent of the federal poverty level. Governor Walker asked the legislature to expand coverage to this group, but the legislature failed to take action on his request. He then told the legislature that he intended to expand coverage under this preexisting provision.

The legislative council, which can sue on behalf of the legislature when it is not in session, sued the governor claiming that expansion of Medicaid coverage was not required and thus Governor Walker's action was illegal. Judge Pfiffner, however, concluded that the Medicaid statute does require coverage of the expansion group. He also concluded that the Supreme Court's National Federation of Independent Business v. Sebelius decision only determined that HHS could not penalize states that failed to expand Medicaid; it did not remove the Medicaid statute's expansion mandate. Thus Alaska law required the expansion and Governor Walker's action was legal.

In a second case, also decided on March 1, 2016, the United States Court of Appeals for the District of Columbia dismissed a case brought by the American Council of Life Insurers challenging an assessment that the District of Columbia's Health Benefits Exchange had imposed on all health insurance policies sold in the District to help finance the exchange.

The lower court had dismissed the case earlier, holding that the assessment violated neither the ACA nor any constitutional provision. The Court of Appeals vacated this judgment, holding rather that the federal district court lacked jurisdiction over the case and should have dismissed it without reaching the merits. The Court of Appeals held that the assessment was a tax, and that federal law vests exclusive jurisdiction for hearing challenges to taxes imposed by the District in the Tax Division of the D.C. Superior Court, therefore the federal district court lacked jurisdiction.

While the D.C. exchange prevailed in this decision, the decision means that the plaintiff can refile its case in the Superior Court and make its legal arguments all over again. The victory is not, therefore, as decisive as an affirmance of the lower court's decision on the merits would have been.

from Health Affairs Blog http://ift.tt/1Y5Aje5