A project of the George Washington University's Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation

Archive: November 2012

OPM issues proposed rule on the multi-state plan program

Posted on November 30, 2012

The Office of Personnel Management (OPM) this afternoon released a proposed rule laying out the guidelines for the Multi-State Plan Program (MSPP). The proposed rule would enable OPM to directly negotiate premiums with insurers and conduct its own rate reviews and resolve appeals. The goal of the program is to promote competition in the insurance marketplace and ensure consumers have more high quality, affordable insurance choices. The Affordable Care Act (ACA) directs OPM to enter into contracts with private health insurance issuers to provide at least two MSPPs to be offered on Exchanges beginning in 2014. At least one of these issuers must be a non-profit entity. Health insurance issuers who wish to participate in the MSPP will apply to OPM. OPM will determine which issuers are qualified to become MSPP issuers, enter into contracts with them, and certify their MSPs to be offered on Exchanges.

Comments are due December 30. Click here for a summary of the rule.

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HHS releases ACA benefit, payment rule

Posted on November 30, 2012

The Centers for Medicare and Medicaid Services (CMS) today released a proposed rule on benefits and payment under the Affordable Care Act (ACA). The proposed rule outlines how CMS plans to run federal exchanges and suggests how risk adjustment data should be collected. The rule also lays out the three-year transitional program that the federal government will run to maintain premium costs in the individual market, and projected that premiums will be 10 to 15 percent lower than they would have been without the reinsurance program. With regard to the reinsurance program, CMS said that federal exchanges can impose a user fee on health plans to finance the exchanges. However, to prevent the user fees from making the health plans less attractive, CMS is asking the Office of Management and Budget (OMB) to exempt the requirement that those fees cover the whole cost in 2014. Before 2014, it wants to cap the monthly fee rate at “3.5 percent of the monthly premium charged by the issuer for a particular policy under the plan.” The goal of the rule is to stabilize the new exchange market, limit risk, and smooth over the transition.

Comments on HHS’s proposed rule are due December 31.

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Essential Health Benefits Update: Proposed Regulations Implementing the ACA; and Application of the Proposed EHB Regulations to Medicaid Benchmark Plans

Posted on November 29, 2012

On November 26, 2012, the Obama Administration published a series of proposed rules implementing many of the Affordable Care Act’s (ACA) most important insurance reforms, including Health Insurance Market Rules and Rate Review (77 Fed. Reg. 70584), Nondiscriminatory Wellness Programs in Group Health Plans (77 Fed. Reg. 70620), and Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (77 Fed. Reg. 70644). In addition, the Administration issued informal guidance that add to and amplify on the provisions of the proposed rules.

This Implementation Brief Update examines the proposed rule implementing the Act’s essential health benefits…

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ONC releases Stage 3 Meaningful Use Request for Comment

Posted on November 27, 2012

The Office of the National Coordinator (ONC) for Health Information Technology’s Health IT Policy Committee (HITPC), which advises the government on its electronic health record incentive program, published recommendations for Meaningful Use stage 3 requirements. These requirements will go into effect in 2016. There is a 45-day comment period on the proposed recommendations, which ends January 14, 2013. The stage 3 objectives, for the most part, reiterate the stage 2 goals, with higher thresholds for demonstrating Meaningful Use.

The stage 3 proposal does introduce some new objectives. One new objective would require providers to give 10% of the patients the ability to submit patient-generated health information. The goal of this requirement would be to improve health outcomes and/or to increase patient engagement in care. Another new objective expands the information that eligible clinicians and hospitals would have to provide at transitions of care. The expanded information requirements would include a care synopsis, setting-specific goals, and instructions for care during the transition. A third new objective is the requirement that providers implement 15 clinical decision support interventions, as opposed to the proposed five in the stage 2 proposal.

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Supreme Court orders Fourth Circuit to hear Liberty case

Posted on November 26, 2012

The Supreme Court on Monday ordered the Fourth Circuit Court of Appeals to examine the constitutionality of the Affordable Care Act’s (ACA’s) employer requirement to cover contraceptives without a co-pay. This move could put the ACA in front of the Supreme Court again as early as next year. The order was in response to a request from Liberty University, one of the groups that sued over the mandate in 2010. After the June ruling, the Supreme Court dismissed Liberty’s entire lawsuit. Over this past summer, Liberty asked the Supreme Court to reopen the arguments pertaining to the employer mandate and the contraceptive coverage mandate. The court agreed to the request and today’s order instructs the Fourth Circuit to review both pieces of the argument.

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CMS releases RFI on quality management and FAQ on Medicaid/CHIP

Posted on November 26, 2012

The Centers for Medicare & Medicaid Services (CMS) released a request for information (RFI), seeking comments regarding health plan quality management in the Affordable Care Act’s (ACA’s) exchanges. In the RFI, CMS said it intends to propose a phased approach to quality reporting. CMS said no new quality reporting standards would be put in place until 2016.

The purpose of the RFI is to seek information regarding what quality improvement strategies health insurance issuers currently use, what opportunities exist to further the goals of the National Quality Strategy through quality reporting requirements in the exchanges, and what factors should be integrated in designing an approach to meaningfully calculate health plan value.

CMS also published a release regarding Medicaid/Children’s Health Insurance Program (CHIP) ACA implementation. In the release, CMS said that Medicaid programs in states that are not expanding Medicaid or building their own exchanges must still coordinate with the federally facilitated exchanges. Beginning in 2014, the ACA requires states to convert to an electronic eligibility and enrollment system for Medicaid and CHIP that makes an eligibility determination based on an applicant’s modified adjusted gross income (MAGI). The new electronic system will also determine eligibility for federal subsidies on the exchange.

The original ACA electronic system upgrades were planned as a part of the nationwide Medicaid expansion. However, in the wake of the June Supreme Court decision, states are no longer obligated to participate in the expansion. This release clarifies that “State Medicaid and CHIP programs will need to coordinate with the federally-facilitated exchange, regardless of a state’s decision to proceed with expansion.”

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HHS releases 3 health care regulations, CBO updates SGR, CMS releases EHB State Medicaid Director letter and Benchmark guide

Posted on November 20, 2012

Today, the U.S. Department of Health and Human Services (HHS) released the essential health benefits proposed rule, the health insurance market rule (which includes standards for premium rates and guaranteed availability and renewability), and a notice of proposed rulemaking (NPRM) on the wellness program.

Also out today is the Congressional Budget Office’s (CBO’s) update to the sustainable growth rate (SGR) formula, pertaining to the Centers for Medicare & Medicaid Services’s (CMS’s) physician payment rule released earlier this month.

CMS’s Center for Medicaid and CHIP Services released a letter to the State Medicaid directors today, which concerns essential health benefits in the Medicaid program.

Finally, CMS released a guide for reviewing proposed State essential health benefits benchmark plans.

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GAO report identifies shortage in Medicaid providers

Posted on November 19, 2012

Medicaid enrollment has grown significantly in recent years and is expected to continue growing as the Affordable Care Act (ACA) potentially extends Medicaid eligibility in 2014 to millions of uninsured Americans. A new Government Accountability Office (GAO) report examines (1) states’ experiences processing Medicaid applications, (2) states’ changes to beneficiary services and provider payment rates, (3) the challenges states report to ensure sufficient provider participation, and (4) the extent to which Medicaid beneficiaries reported difficulties obtaining medical care.

With regard to the first finding, from 2008 to 2011, more than half of states reported maintaining or decreasing their average Medicaid application processing times. Second, states reported making numerous changes to provider payments, provider taxes, and beneficiary services since 2008. While more states reported provider-rate and supplemental payment increases each year from 2008 through 2011, the number reporting payment reductions and increased provider taxes also grew. Third, over two-thirds of states reported challenges to ensuring enough Medicaid providers to serve beneficiaries–including dental and specialty care providers. Finally, in calendar years 2008 and 2009, less than 4 percent of beneficiaries who had Medicaid coverage for a full year reported difficulty obtaining medical care, which was similar to individuals with full-year private insurance; however, more Medicaid beneficiaries reported difficulty obtaining dental care than those with private insurance.

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Judge exempts religious company from ACA’s contraception requirement

Posted on November 19, 2012

On Friday, U.S. District Judge Reggie Walton granted a preliminary injunction to Tyndale House Publishers, enabling the company to reject the Affordable Care Act (ACA) provision which requires employers to provide its employees with contraceptive coverage. The company argued that it does not want to cover contraceptives, as it  views them as abortions.

Plan B and IUDs are the contraceptives at issue in the case. If a woman is already pregnant, the Plan B pill has no effect. Plan B merely prevents ovulation or fertilization of an egg. Plan B can also prevent a fertilized egg from implanting on the uterine wall. IUDs mainly work by blocking sperm, but may also have the same anti-implantation effect. According to Tyndale, this implantation prevention is not morally different than abortion.

Tyndale president and CEO Mark D. Taylor filed the lawsuit against the U.S. Department of Health and Human Services (HHS) last month, arguing that the provision causes employers to violate their religious beliefs.

In his decision, Judge Walton acknowledged that the government has interests in promoting public health and ensuring that women have equal access to health care, but he said that the government has not offered proof that the ACA’s contraceptive coverage provision furthers these interests.

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RWJF/Health Affairs article explores BHP implementation

Posted on November 19, 2012

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation examines how the Basic Health Program (BHP) may enable states to offer eligible residents health insurance that is more seamless than coverage in the private insurance market. Because Medicaid eligibility and federal subsidies are determined by income compared to the federal poverty level, individuals can gain or lose eligibility for subsides as their incomes fluctuate. This phenomenon—known as churning—can be very disruptive to maintaining steady health insurance coverage.

According to the report, it has been estimated that within six months of enrollment, more than one-third of all low-income adults (about 28 million people) may experience enough of a change in income to churn between Medicaid, buying insurance through an exchange, or losing eligibility for subsidies. Supporters of the Affordable Care Act’s (ACA’s) BHP argue that the program will make coverage more affordable for low-income people and has the potential for some states to save money. Opponents worry that the program could undermine the new state insurance exchanges and thus runs the risk of exposing states to financial risk.

The report concludes that whether states decide to establish a BHP or not will depend on plans for Medicaid expansion and exchange establishment.

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