Over the past month, several significant proposed federal regulations and guidance have been released regarding essential health benefits, exchange design and operation, and preventive services coverage. States
have also moved ahead with efforts to prepare systems, providers, and
consumers for the 2014 insurance expansions. The most recent federal
updates as well as state implementation highlights are discussed in
detail below. Action steps
are also included to support engagement in state health reform
implementation decision making. For questions about health reform or
action steps, please contact Amy Killelea.
In This Edition
NASTAD Blog: The Most Recent Health Reform Posts
Federal Implementation Updates
State Implementation Updates
Health Reform Resources
NASTAD Blog: The Latest Health Reform Posts
In our ongoing efforts to improve NASTAD communications, we are piloting a new web blog
to provide more ways for you to receive timely, accurate, and high
quality content. Please stay tuned for more details as we complete this
transition. Below are the latest health reform blog posts. Please send
questions, comments, and suggestions to Meico Whitlock.
Health Reform Blog Posts
Federal Implementation Updates
Medicaid Essential Health Benefits
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ACTION STEP: Find
out if your state Medicaid office has chosen a benefits package for
newly eligible beneficiaries and whether this package will be different
from the traditional Medicaid package.
In January, the Department of Health and Human Services (HHS) published a much-awaited proposed rule
spelling out the “Essential Health Benefits” (EHB) requirements for
newly eligible Medicaid beneficiaries (those ineligible for Medicaid
under current Medicaid rules who will be eligible under the ACA in 2014
if states opt to expand). The proposed rule indicates that states will
have a great deal of flexibility in designing Medicaid benefits packages
for the expansion population – states may opt to make this package very
similar to its traditional Medicaid package or opt to more closely
align it with private insurance plans. In addition, the rule included
troubling proposals to allow states to increase the cost-sharing
obligations of all Medicaid beneficiaries for certain prescription drugs
and for non-emergency care sought in an emergency room. NASTAD will
submit comments in response to the rule, focusing on areas identified in
the recent blog post on this issue.
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Preventive Services in Medicaid
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ACTION STEP: Find out if your state Medicaid office is adding these preventive services to its Medicaid package.
On February 1, 2013 the Centers for Medicare and Medicaid Services (CMS) issued a State Medicaid Director Letter
providing guidance to states that opt to offer certain preventive
services without cost sharing. Beginning January 1, 2013, the ACA allows
states to receive a one percent increase in federal matching dollars
for offering specified preventive services without cost sharing, including
services assigned a grade of A or B by the United States Preventive
Services Task Force (USPSTF) and vaccines recommended by the Advisory
Committee on Immunization Practices (ACIP). This will include
routine HIV screening as well as hepatitis C screening for those at increased risk if the new recommended USPSTF grades are adopted.
(Note: While these services are optional under traditional Medicaid,
the proposed EHB rule for Medicaid for newly eligible beneficiaries
clarifies that these services are required for the newly eligible
group). The letter also specified that a state must offer all of
the listed preventive services to get the enhanced federal match.
Finally, the letter highlights a proposed departure from current
Medicaid rules that currently limit reimbursement for preventive
services to physicians and licensed practitioners under state scope of
practice rules. The letter references a proposed Medicaid rule that, if
adopted, would give states the ability to allow non-physician providers to provide these preventive services when recommended
by a physician or other licensed practitioner provider rather than
exclusively provided by a physician or licensed practitioner. Increasing
the ability of non-physician providers to be reimbursed for these
services could have a significant impact on HIV and viral hepatitis
testing, which is often performed by a range of community-based
providers.
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Eligibility for Advance Premium Tax Credits
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ACTION STEP:
Determine how many clients will be priced out of health insurance
subsidies because of this rule and what safety net services are
available (e.g., ADAP).
The Internal Revenue Service (IRS) published a final rule on eligibility for Advance Premium Tax Credits (APTC)
to help consumers afford private insurance purchased through exchanges.
To be eligible for APTC, a person must have income between 100 and 400
percent FPL and not have access to “minimum essential coverage.” The
rule defines minimum essential coverage as access to
government-sponsored health care (e.g., Medicaid) or affordable employer
sponsored coverage. The rule defines affordability as
employer-sponsored coverage that is not more than 9.5 percent of
household income. However, in a very narrow interpretation of the law,
the rule bases its definition of affordability on a self-only plan, not
on a family plan. This means that uninsured family members of employees
with access to affordable self-only employer coverage cannot qualify for
a premium tax credit even if dependent coverage offered by an employer
ends up exceeding 9.5 percent of household income.
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Exemptions from Individual Mandate
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ACTION STEP: Ensure that consumers are aware of the exemptions from the penalty for not having insurance coverage.
The IRS and CMS released proposed rules with regard to the ACA’s individual requirement to purchase health insurance. The rules clarify the list of exempt groups
specified in the ACA who will not be subject to the penalty for not
having insurance coverage in 2014. Importantly, the rules introduced a
new exemption in direct response to the Supreme Court’s decision on the
Medicaid expansion. Individuals who would have otherwise been eligible
for the ACA’s Medicaid expansion in a state that opts not to comply with
the expansion will not be subject to the penalty. This new exemption
will be important in states that do not expand to ensure that
individuals who would have been eligible for Medicaid are not penalized.
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Exchanges
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ACTION STEP:
Engage in discussions with state departments of insurance and Medicaid
programs to ensure that Ryan White Program providers are included in
exchange and Medicaid managed care networks.
On January 3, 2013, HHS published guidance to states that opt to operate a partnership exchange
(the model in which states and the federal government share
responsibility for certain exchange functions). An important piece of
the guidance shed light on how HHS is proposing to define “network
adequacy” standards for plans sold in the exchanges. The language in the
guidance surrounding inclusion of “Essential Community Providers” (ECP)
in plan networks – which in previous rules have been defined to include
certain Ryan White providers – are somewhat weak. While every plan must
include a sufficient number of ECPs in their networks, the rules around
how many ECPs must be included are vague. NASTAD and other provider
advocates continue to push for an explicit inclusion of Ryan White
Program providers and sub-contracted grantees as ECPs as well as network
adequacy standards that ensure at least one Ryan White Program provider
in each plan network. However, a weak federal standard will mean that
ensuring that Ryan White Program providers are included in plan networks
will be a state by state and plan by plan effort. States have until
February 15, 2013 to submit a blueprint to HHS for a partnership
exchange. Kaiser Family Foundation is tracking state declarations with regard to state-run, partnership, or federally facilitated exchanges.
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Single Streamlined Application Template for Health Insurance Coverage
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ACTION STEP:
Ensure that case managers and outreach workers are familiar with the
application materials and process for new coverage options in
2014.
State Implementation Updates
In the past month, state health reform planning activities have
continued. The following are examples of activities happening in states:
Medicaid Expansion
As state advocacy efforts around the individual health, public health,
and economic benefits of Medicaid expansion ramp up, there has been a
growing trend of state acceptance of the expansion, even in states that
had indicated initial political opposition to the ACA. The map below
produced by the Center on Budget and Policy Priorities
sums up the growing trend towards support of the Medicaid expansion (as
of mid-January 2013). Over the past several weeks, there has been a
growing trend among governors – many of whom were initially opposed to
the ACA – to embrace the Medicaid expansion, with governors from Michigan, Ohio, Arizona, Nevada, and New Mexico being the most recent to announce support.
Health Department Planning Activities
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Indiana recently hosted its annual HIV Care
Coordination Program Manager meeting. The two-day meeting convened case
management program directors from all over the state and devoted a
significant amount of time to discussion and planning for ACA
implementation in Indiana. A state Medicaid representative was invited
to share updates with regard to state planning and implementation of
Medicaid reforms and exchange operation. Health department officials
used the training as an opportunity to discuss proposed program changes
needed to adapt to a changing health care environment – including
transition plans for clients who will lose coverage when the state and
federal high risk pools close on December 31, 2013. NASTAD was also
involved in the training, facilitating a discussion of how the ACA will
impact HIV/AIDS programs and highlighting opportunities for case
management involvement. The presentation is available here.
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The Washington State Department of Health recently
hosted a similar case management training, highlighting the impact that
ACA implementation will have on HIV/AIDS programs. Unlike Indiana,
Washington has elected to set up its own state-run exchange and is
likely to comply with the Medicaid expansion in 2014. NASTAD facilitated
a discussion of what these changes will mean for HIV/AIDS providers and
consumers. The health department intends to convene a series of
meetings and trainings over the coming months, aimed at preparing
providers for health reform implementation.
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AIDS Drug Assistance Program (ADAP) Planning
NASTAD is continuing its intensive efforts to prepare ADAPs for ACA
implementation, particularly with regard to the ability of ADAP to
provide insurance assistance for clients to purchase insurance through
exchanges. Over the coming months, NASTAD will be convening a
series of meetings and webinars on this issue. The first webinar will be
focused on exchanges and is scheduled for February 27, 2013. A formal
invitation for this webinar will be sent out shortly.
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Health Reform Resources
For questions or for suggestions for NASTAD health reform resources that
would be helpful to your program or questions about action steps,
please contact Amy Killelea.
In addition, HRSA’s HIV/AIDS Bureau has created a mailbox (RWP-ACAQuestions@hrsa.gov) where questions related to implementation of the ACA can be submitted.
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