Medicaid and CHIP
Update: The IRS’ Final Shared Responsibility Regulations: When Does Medicaid Eligibility Amount to “Minimum Essential Coverage”?
Posted on September 4, 2013
On August 30, 2013, the IRS published final regulations implementing the shared responsibility provisions of the Affordable Care Act (78 Fed. Reg. 53646-53664). The regulations address, among other matters, the complex question of when Medicaid eligibility amounts to minimum essential coverage (MEC) for purposes of the Act’s tax penalties. Because people with MEC are barred from receiving premium and cost sharing assistance for Marketplace plans, the final rules also have important implications in the area of health policy for children and adults with disabilities, who may need both basic insurance and supplemental Medicaid coverage for their more extensive health care needs. Many of Medicaid’s most important disability-related eligibility categories are optional with states and, therefore, monitoring whether and how agency policy on when Medicaid counts as MEC will be an important issue to watch over time.
Update: Final Rule on Medicaid and CHIP, Including Essential Health Benefits in Alternative Benefit Plans; Eligibility Notices, Fair Hearings and Appeals Processes; Premiums and Cost Sharing; and Exchange Eligibility and Enrollment
Posted on July 16, 2013
On July 5, 2013, the Obama Administration published final rules implementing various provisions of the Affordable Care Act related to Medicaid and CHIP, premiums and cost-sharing, and Exchange eligibility and enrollment. This Update discusses the highlights of this very long rule, which modifies final regulations published in March 2012 as well as previous proposed regulations. The final rule contains four major parts: A. Medicaid Eligibility Part II Final Rule B. Essential Health Benefits in Alternative Benefit Plans C. Exchanges: Eligibility and Enrollment D. Medicaid Premiums and Cost-sharing In general, the final rule was adopted with very few changes. At the same time, CMS noted that certain aspects of the proposed rules remain un-finalized, pending additional implementation activities, including further changes necessitated by the Administration’s decision to delay employer compliance-related reporting requirements in connection with the Act’s employer responsibility provisions.
Categories: Medicaid and CHIP
Posted on June 19, 2013
This Implementation Brief Update discusses CMS’ May 17, 2013, State Health Official Letter, the purpose of which is to advise states on options to facilitate Medicaid and CHIP enrollment and renewal. The letter lays out “optional strategies that can help make significant progress toward reducing the number of uninsured individuals” as well as “optional tools to help states manage the transition to their new eligibility and enrollment systems and coverage of new Medicaid enrollees.” The letter is intended to help states make the transition to the simplified Medicaid and CHIP enrollment system that must be in place in all states beginning January 1, 2014, in accordance with ACA §2201. The mandatory nature of the enrollment simplification requirement was not affected by the United States Supreme Court’s decision in NFIB v Sebelius, which permits states to opt out of the adult Medicaid eligibility expansion group...
Posted on June 13, 2013
For thirty years, the Medicare and Medicaid programs have furnished additional payments to hospitals that furnish a disproportionate share of services to low income populations. Despite the fact that the two disproportionate share hospital (DSH) programs share a common mission, they function differently in terms of how the funds actually move to hospitals and in the formulas used to make DSH payments. The Affordable Care Act makes significant adjustments in both DSH programs beginning in 2014 in anticipation of a significant expansion in the proportion of people who have health insurance coverage. With the United States Supreme Court’s decision in 2012 in NFIB v Sebelius, which permits states to opt out of the Medicaid expansion without risking the loss of federal funding for their existing Medicaid programs, the downward DSH payment adjustments become an even more significant matter for hospitals that treat large volumes of low income patients...
CMS State Resources FAQ: Medicaid Eligibility Determinations, Medicaid/Exchange Interactions, and §1115 Demonstrations that Use Enrollment Caps
Posted on May 22, 2013
The interaction between Medicaid and Exchanges around eligibility determination issues represents one of the most important and complex aspects of the ACA. An estimated 28 million adults, along with 19 million children, can be expected to transition at least once annually between insurance affordability programs, as Medicaid and premium subsidies are termed under implementing CMS regulations. Collaboration between Medicaid agencies and Exchanges is essential in order to avert unnecessary delays in eligibility determinations and breaks in coverage that in turn can affect not only the affordability of care but access itself, given the link between coverage and health care access through plans’ provider networks...
Posted on March 13, 2013
On February 25th, 2013, final regulations implementing the essential health benefit (EHB) provisions of the Affordable Care Act were published in the Federal Register (78 Fed. Reg. 12834-12872). The EHB rules, which amend 45 C.F.R., apply to all non-grandfathered individual and small group health plans sold after January 1, 2014, as well as Medicaid benchmark and benchmark-equivalent health plans. The EHB rules also apply to...
Posted on March 7, 2013
On February 28th, 2013, Politico reported that Arkansas Governor Mike Beebe had received approval “to take federal Medicaid expansion money and use it to buy private health coverage for low-income residents through the state’s insurance exchange.” This Implementation Brief explains the legal basis for this decision, as well as the issues that can be expected to arise in using this approach to coverage.
Posted on February 27, 2013
On February 6, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a new series of ACA-related Frequently Asked Questions (FAQs). The first two questions address the Basic Health Program (BHP). As described in an earlier Implementation Brief, the BHP was included in the ACA as a special state coverage option for low-income families and individuals. In answer to the question “When will the Basic Health Program be operational?”, CMS replied that the agency does not intend to propose implementing rules until sometime in 2013 and furthermore, that final rules will not be issued until 2014. The status of the Basic Health Program emerged as one of the subjects of a Senate Finance Committee’s ACA oversight hearing on February 14, 2013, during which Senator Maria Cantwell (D-WA), who sponsored the legislative amendment creating the BHP, questioned CCIIO Director Gary Cohen on the timing of BHP guidance.
Update: Medicaid Preventive Services Coverage Incentive for Traditional Adult Beneficiaries Covered Under the Standard Medicaid Program
Posted on February 21, 2013
Preventive services are optional for traditional Medicaid beneficiaries ages 21 and older who are covered under the standard Medicaid program. Young adults ages 18-21 remain entitled to EPSDT benefits, which encompass periodic and as-needed health exams, all age-appropriate immunizations, and other preventive services.
Posted on February 7, 2013
This Update begins with a summary of federal policy guidance on health insurance Marketplaces that has been issued to date. It then presents in its entirety an interview with Gary Cohen, conducted by Professor Sara Rosenbaum of GW on January 29, 2013. The Update concludes with some observations about key issues that will arise as implementation of the federal Marketplace proceeds.
UPDATE: When Should Uninsured Family Members of Employees with Access to Affordable Self-Only Employer Coverage Qualify for Premium Tax Credits?
Posted on February 1, 2013
As noted in a previous Implementation Brief , the Affordable Care Act (ACA) allows for premium assistance through tax credits for the purchase of family coverage from qualified health plans sold through health insurance marketplaces. To be eligible for tax credits, individuals must not otherwise be “eligible for minimum essential coverage” and must have annual incomes of 100-400 percent of federal poverty level. With regard to individuals who are offered employer-sponsored coverage, the law states that in order to qualify for the premium tax subsidy, the employer-sponsored coverage must be deemed unaffordable, defined by the IRS as an employee contribution requirement for self-only coverage that exceeds 9.5 percent of household income. Although the ACA extends eligibility for assistance (based on the affordability test) to workers’ dependents, the remaining question, as noted in another earlier Brief, was whether uninsured family members of employees with access to affordable self-only employer coverage can qualify for a premium tax credit. The IRS answered that question...
Posted on January 25, 2013
On January 14, 2013, HHS issued a Notice of Proposed Rulemaking (NPRM) whose aim is to address a number of issues that arise at the intersection of the three principal federal “insurance affordability programs” established or modified under the Affordable Care Act (ACA): Medicaid; the Children’s Health Insurance Program (CHIP); and the advance premium tax credits and cost sharing reduction assistance available to individuals who apply for coverage in Exchanges. The proposed rules seeks to more closely align these pathways in several basic respects: the process...
Posted on January 16, 2013
Experts and stakeholders agree the current health care system is unsustainable. By 2020, health care spending will comprise almost 20% of the gross domestic product. Furthermore, an ever growing body of evidence clearly indicates that the system is not experiencing improvements in quality that are reflective of the cost growth. The Patient Protection and Affordable Care Act (ACA) takes significant strides towards the transformation of the American health care delivery system from a system that rewards volume to a system that rewards quality and value. The programs and initiatives...
Posted on January 8, 2013
Both the Senate and the House passed H.R.8 (89-8 and 257-167, respectively), the American Taxpayer Relief Act, on January 1, 2013. President Barack Obama signed the Act into law on January 3, 2013. The measure extends Bush-era income and other tax cuts for individuals and families making up to $400,000 and $450,000 respectively. For individuals and families above this income threshold, the bill increases taxes from 35% to 39.6%. H.R. 8 also postpones...
Posted on January 3, 2013
On November 6, 2012, the Centers for Medicare and Medicaid Services (CMS) published final rules (77 Fed. Reg. 66670-66701) implementing an Affordable Care Act (ACA) provision whose purpose is to temporarily increase state Medicaid payments for primary care services. The ACA requires that state Medicaid agencies pay for primary care furnished by physicians in 2013 and 2014 at least...
Posted on December 19, 2012
This Update summarizes the CMS Frequently Asked Questions (FAQ) document issued on December 10, 2012.
Update: CMS’s Frequently Asked Questions on Market Reforms and Medicaid—Can States Cover Less than all Newly Eligible Individuals under the ACA 2014 Medicaid Eligibility Expansion and Still Receive Enhanced Federal Funding?
Posted on December 11, 2012
On December 10, 2012, the Centers for Medicare and Medicaid Services (CMS) released a long-awaited set of frequently asked questions on Exchanges, market reforms, and Medicaid. We will post a further analysis of these FAQs in the near future, but we rush to post one question and answer because of its significance in relation to the Medicaid expansion...
Posted on December 5, 2012
Beginning January 1, 2014, millions of previously uninsured individuals will gain access to health insurance coverage under the Affordable Care Act (ACA). On November 20, 2012, the Obama Administration proposed a series of regulations that move the nation significantly toward full implementation. These proposed rules will be analyzed at greater length in coming GPS Implementation Brief updates. In the meantime, this overview summarizes the major federal implementation matters that the Administration has recently released or is expected to address in policy or program implementation in the coming weeks and months as the 2014 full implementation date approaches. Together, these matters address...
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...
Posted on November 14, 2012
Historically, the American health care system through its siloed delivery and reimbursement models has failed to support a patient-centered and coordinated delivery system. Fragmentation has resulted in a health care system where potentially avoidable hospital readmissions, duplicative testing, and medication errors are common. Widespread adoption and use of Health Information Technology (HIT) has the potential to decrease these occurrences by enabling providers to electronically exchange health information with other providers and their patients across settings of care to better coordinate patient care. Recognizing the potential benefit of widespread use of HIT, in 2009 Congress authorized...
Posted on September 26, 2012
The Affordable Care Act (ACA), in addition to expanding coverage to individuals with incomes below 133 percent of the federal poverty level (FPL), includes provisions designed to preserve existing Medicaid coverage -- known as the maintenance of effort provision, or MOE -- until the ACA is fully implemented. The ACA’s MOE provision requires states to maintain their current Medicaid eligibility standards, methodologies, and procedures until the Secretary of the Department of Health and Human Services (HHS) determines that a state Exchange is fully operational. For children, the ACA’s MOE extends through September 30, 2019. States may reduce eligibly for certain non-pregnant, non-adult...
Congressional Budget Office and Joint Tax Committee Estimates of Cost and Coverage under the ACA after the Supreme Court Ruling in NFIB v. Sebelius and the Effects of H.R. 6079, the Repeal Obamacare Act
Posted on August 1, 2012
The Congressional Budget Office (CBO), the legislative branch agency responsible for estimating the cost of legislation, issued two reports on July 24th related to the Affordable Care Act (ACA). The first report, revised cost and health insurance coverage estimates for the ACA in the wake of the Supreme Court ruling in NFIB v. Sebelius. In that ruling, the Court concluded the individual requirement to purchase health insurance coverage, while not a reasonable exercise of congressional Commerce Clause authority, is constitutional as a tax under congressional Spending Clause authority. The Court also held that the ACA’s Medicaid expansion, requiring states to cover all non-elderly individuals with incomes below 133 percent of the federal poverty level was unconstitutional. However, rather than striking the requirement, the Court precluded the Secretary of the Department of Health and Human Services (HHS) from enforcing the mandate by withholding all Medicaid funds. As a result of the ruling, states now have the option of expanding coverage to 133 percent of the federal poverty level (FPL), and will receive enhanced federal matching funds as provided under the law, but are not required to expand coverage.
Posted on July 18, 2012
The Affordable Care Act (ACA) included a number of provisions designed to improve the delivery of health and long-term care support services for individuals who are eligible for and enrolled in both the Medicare and Medicaid programs, commonly referred to as “dual eligible.” An earlier Health Reform GPS Implementation Brief outlined these changes. Among the provisions identified in the Brief was new demonstration authority provided to the Department of Health and Human Services (HHS) to permit states to waive certain provisions of Medicare law to better coordinate care for dual eligibles, new grant funding available to as many as 15 states to plan and implement integrated programs of care for dual eligibles, and the release of a July 11 State Medicaid Director (SMD) Letter providing preliminary guidance to states on demonstration models designed to improve care coordination for dual eligibles, including both capitated and fee-for-service models. This Brief provides an update on the financial alignment model outlined in the SMD letter, with a focus on subsequent guidance to states and health plans seeking to participate in capitated demonstrations. This demonstration is being followed closely at the federal level, and both...
Posted on July 3, 2012
In NFIB v Sebelius the United States Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (ACA or the Act). At the same time, the decision adds a new dimension to the implementation of §2001(a) of the Act, which establishes expanded Medicaid eligibility for certain low-income people. This Implementation Brief begins with a discussion of exactly what the Court held in its Medicaid ruling. It then discusses the significance of the majority conclusion, as well as the key implementation questions that arise in the wake of this opinion.
Summary of the U.S. Supreme Court decision in the case of National Federation of Independent Businesses et al. v. Sebelius, Secretary of Health and Human Services, et al.
Posted on June 28, 2012
The Supreme Court handed down its long-awaited ruling in the case of National Federation of Independent Businesses et al. v. Sebelius, Secretary of Health and Human Services, et al., upholding the individual requirement to maintain insurance coverage as a reasonable exercise of Congress’s taxing and spending authority and also upholding the constitutionality of the Medicaid coverage expansion. In a surprise coalition, Chief Justice Roberts was joined in his majority opinion by Justices Stephen Breyer, Ruth Bader Ginsburg, Sonia Sotomayor and Elena Kagan. The summary below describes the majority opinion, the concurring opinion (authored by Justice Ginsburg), and the dissenting opinion (written by Justice Scalia). Because the Court upheld the individual mandate, it never reached...
Posted on June 7, 2012
A primary goal of the ACA is to increase consumer choice by stimulating market competition among health plans to offer more affordable, value-based options through the new insurance exchanges. The state health insurance exchanges are designed to provide consumers choices among pre-approved health plans that meet certain federal standards ranging from the provision of specific benefits to anti-discriminatory requirements for consumers with pre-existing health conditions. Only plans that meet these standards – the qualified health plans or QHPs – will be allowed to participate in the exchanges. To foster competition, particularly in markets where one insurer holds a significant share, the ACA also requires two QHPs participating in each exchange to be multi–state plans or MSPs. Unlike other QHPs participating...
Increased Medicaid Payment for Primary Care Services Under the Affordable Care Act: Overview and CMS Implementation
Posted on May 30, 2012
Low physician participation rates in Medicaid -- virtually since the program’s 1965 enactment -- have long posed a key limitation to its effectiveness. Many factors are thought to account for limited physician participation but, historically, low payment rates have stood out as a primary underlying problem. As of 2008, Medicaid physician fees stood at approximately 72 percent of Medicare fees...
Posted on March 23, 2012
On March 16, 2012 the Centers for Medicare and Medicaid Services (CMS) released a final rule regarding Medicaid eligibility under the Affordable Care Act. A summary of the final rule was previously posted on healthreformgps.org. This Update summarizes the key provisions of the final regulation, which also contains certain interim final rules on which further comment is sought. The Final Rule, which takes effect January 1, 2014, addresses a wide array of issues raised in the 2011 proposed rule.
Posted on January 26, 2012
Improving the quality of care delivery and reducing explosive growth in healthcare costs is a cornerstone of The Patient Protection and Affordable Care Act (ACA). It reflects the shared understanding that the current silo-based approaches to care delivery that focus on settings of care (e.g., physician office, hospital) rather than care delivery across multiple providers and setting (e.g., episodic) are not working. Costs are increasing at an unsustainable pace, and evidence from leading researchers collectively points to serious deficiencies in health care quality and the disconnect between high spending and health care quality. To foster the development of more collaborative and...
Update to Health Insurance Exchanges–Exchange Functions in the Individual Market: Eligibility Determinations and Exchange Standards for Employers
Posted on September 1, 2011
This Update to the health insurance Exchange Implementation Brief examines a proposed regulation issued on August 17, 2011 as part of three proposed rules to implement provisions of the Affordable Care Act related to health insurance affordability. Companion Updates explain the proposed Medicaid eligibility rule and the proposed rule related to health insurance premium tax credits; this Update focuses on Exchange functions related to determinations of eligibility for “Exchange participation and insurance affordability programs,” as well as standards for employer participation.
Posted on August 31, 2011
This update to the Medicaid Implementation and health insurance Exchange Briefs reviews a Notice of Proposed Rulemaking (NPRM) implementing the Medicaid and CHIP eligibility, enrollment simplification, and coordination provisions of the Affordable Care Act. Issued by the United States Department of Health and Human Services on August 17, 2011, the rule is comprehensive in scope; its public comment period ends October 31, 2011. The Medicaid NPRM is part of a group of three regulations, all of which are summarized at HealthReformGPS.org. Together the rules are designed to implement both the Medicaid eligibility expansions, the process of determining eligibility for premium tax credits and cost sharing assistance in the Exchange individual market, and standards for employers purchasing coverage in Exchanges. Collectively, the rules are designed to allow individuals and families to acquire and keep coverage and move more seamlessly among publicly-supported sources of health insurance as family income and circumstances change.
Posted on August 10, 2011
According to the Centers for Medicare and Medicaid Services (CMS), in 2008 there were an estimated 9.2 million individuals who were eligible for and enrolled in both the Medicare and Medicaid programs (commonly referred to as “dual eligibles”). Two-thirds of dual eligibles qualify because they are over age 65, while the other third qualify because of a disability. Dual-eligible beneficiaries typically have multiple chronic conditions that require a higher level of care and result in increased spending relative to other Medicare and Medicaid beneficiaries; however, their care is not usually coordinated. Policymakers have expressed concern that the lack of coordination between the two programs results in higher costs and poorer health outcomes than would be achieved if Medicare and Medicaid services were better integrated.
Posted on June 29, 2011
An important issue in implementing the Affordable Care Act (ACA) is how to address the needs of uninsured low-income individuals and families whose incomes exceed Medicaid eligibility levels but are less than twice the federal poverty level (about $37,000 for a family of 3 in 2011). Under the ACA, the basic approach to assisting such individuals and families is the state health insurance Exchange, which enables qualified individuals to secure coverage and provides access to premium assistance and cost-sharing subsidies aimed at making coverage and care affordable.
Posted on June 8, 2011
A high number of deaths occur every year due to potentially preventable adverse events, including medical errors, in the hospital setting. The most commonly cited research on this topic was published by the Institute of Medicine (IOM) in 1999. The IOM report, "To Err is Human: Building a Safer Health System" stated that hospital acquired conditions (HACs) caused by medical errors are a leading cause of morbidity and mortality in the United States. More recently, a 2007 study found that of 1.7 million infections acquired while a patient was receiving treatment in a hospital, 99,000 resulted in death in 2002. In addition, there is also a significant cost burden associated with potentially preventable HACs. In 2000, the Centers for Disease Control and Prevention (CDC) published a report estimating the cost burden of HACs to be almost $5 billion.
Categories: Medicaid and CHIP
Posted on May 26, 2011
Access to health care has been a prime focus of the Medicaid program since it’s enactment in 1965. A key aim of the Medicaid statute has been to integrate Medicaid beneficiaries into the general health care system, affording them insurance coverage that would enable them to secure care from the participating provider of their choice in a manner similar to that enjoyed by privately insured individuals and Medicare beneficiaries. It is evident, however, that despite Medicaid’s enormous achievements, access to “mainstream” medical care has remained elusive.
Posted on May 13, 2011
House and Senate Republicans introduced legislation to permit states, effective on the date of enactment, to repeal both the ARRA MOE provisions and the Medicaid and CHIP MOE provisions included in the ACA. The State Flexibility Act (H.R. 1683) was introduced in the House of Representatives by Rep. Phil Gingrey (R-GA). The Senate companion legislation (S. 868) was introduced by Senator Orrin Hatch (R-UT), ranking member of the Senate Finance Committee. Supporters of the State Flexibility Act argue that the MOE limits the ability of states to lower Medicaid spending and balance state budgets.
Categories: Medicaid and CHIP
Posted on April 6, 2011
Medicaid provides health insurance to the poorest and most medically vulnerable populations. Low-income pregnant women, children, and very poor parents of minor children are the majority of beneficiaries; Medicaid also provides coverage for children and adults with severe disabilities, as well as “wrap-around” coverage for low-income Medicare beneficiaries who cannot pay for services and cost-sharing that Medicare does not cover, particularly institutional and home- and community-based long-term care. Medicaid is jointly funded by states and the federal government and administered by states under broad federal standards.
Posted on March 11, 2011
A recurring health reform theme over the years has been the “essential community provider.” Originated as an aspect of President Clinton’s health reform plan, the term has been used by policymakers and researchers alike to denote health care providers that through legal obligation or mission, organizational and service structure, and patient population characteristics, play a significant role in health care for patients and populations at disparate risk for inadequate access. Examples of patient populations reached by essential community providers include uninsured and underinsured persons, residents of medically underserved urban and rural communities that experience primary health care shortages, children with special health care needs and serious and chronic conditions, adults with mental illness and substance use disorders, disadvantaged patients who seek family planning and primary reproductive health services, seriously and chronically ill and disabled low-income populations including Medicare/Medicaid “dual enrollees,” homeless individuals, persons with HIV/AIDS, high risk pregnant women and newborns, and farm workers and their families.
Categories: Medicaid and CHIP
Posted on March 9, 2011
In recessionary times, states seek to reduce Medicaid spending; paradoxically, this is when the need for public insurance may be the highest. During the recession that occurred in the early 2000s, two-thirds of all states reduced Medicaid eligibility, removing between 1.2 and 1.6 million children and adults from the program before Congress enacted legislation barring further cuts as a condition of additional federal assistance. The current recession is far more serious, and state budget shortfalls, far greater.
Categories: Medicaid and CHIP
Posted on March 7, 2011
Family planning services and supplies for individuals of childbearing age (including sexually active minors) who desire such services is a required benefit under federal Medicaid law. Although all state Medicaid programs must cover family planning services, many states’ Medicaid eligibility standards for adults of childbearing age are so low that family planning (and other essential) Medicaid benefits reach only a fraction of the poor. Simply being low-income is not a recognized eligibility category for adults as it has been for children since Medicaid’s 1965 enactment. Beginning several years ago, a number of states began to build on Medicaid eligibility expansions for pregnant women in order to extend this expanded eligibility to non-pregnant women for family planning and related services, rather than the full Medicaid benefit package.