Health Reform Watch is a newsletter for state and territorial health department staff that provides updates, analysis, and highlights on federal and state health reform activities. This newsletter is intended to inform state and territorial health department staff about ongoing health reform activities.

Health Reform Watch

Volume 5, June 12, 2013
Open enrollment is less than four months away, and states and federal agencies are rapidly preparing outreach, application, and enrollment systems to ensure a smooth transition to coverage. Federal guidance and regulations on Pre-existing Condition Insurance Plans (PCIPs), Medicaid eligibility and ACA outreach and enrollment opportunities have significant implications for state HIV/AIDS and hepatitis programs, providers and people living with HIV and viral hepatitis. The most recent federal and state updates as well as health department implementation highlights are discussed in detail below. For questions, please contact Amy Killelea.

In This Edition

NASTAD Blog: The Latest Health Reform Posts

Below are the latest health reform blog posts. Please send questions, comments, and suggestions to Meico Whitlock.

Health Reform Blog Posts

Federal Implementation Updates

Pre-existing Condition Insurance Plan (PCIP) Changes

  • ACTION STEP: Assess impact of transition to federal PCIP and work with state PCIP to notify clients about transition.
In April of 2013, the federal government altered its contract with the 27 state-run Pre-existing Condition Insurance Plans (PCIPs). States were notified that for the remainder of the year, the state-run PCIP would receive a capped amount of funding for the program. States were given the choice of either taking on the risk to cover any costs above that cap or transitioning current state-run PCIP clients to the federally run PCIP. Seventeen states chose to transition clients to the federal PCIP, while ten states will continue to operate the state-run PCIP. In a recent call with representatives from the Centers for Medicare and Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO), the following information about how clients will be transitioned was provided: 
  • State-run PCIP clients will be auto-enrolled into the federal PCIP, meaning they will not have to fill out a new application. Clients will receive notices from CCIIO about the transition in June, including a benefits card. Coverage in the federal PCIP begins July 1, 2013.
  • Information about annual deductibles and cost sharing already paid could not be transferred from the state-run PCIPs to the federal PCIP. To avoid double billing clients (and ADAPs), the deductibles and cost-sharing caps will be reduced by 50% for clients transitioning to the federally run PCIP on July 1, 2013.
  • Any provider may participate in the federally run PCIP (as long as they are willing to accept newly announced Medicare-based reimbursement rates), meaning that clients transitioning from state-run PCIPs should have access to the same provider. However, the federal PCIP uses Medco/Express Scripts for pharmacy benefits, which may be different from the pharmacy used by the state-run PCIP. 
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Medicaid Guidance on Eligibility and Enrollment and 1115 Waivers
  • ACTION STEP: Find out whether your Medicaid program is using optional strategies to simplify Medicaid eligibility and monitor state 1115 waiver proposals.  
New State Options for Simplified Medicaid Eligibility and Enrollment

In April, CMS released a letter to state health officials and Medicaid Directors highlighting several strategies to simplify Medicaid eligibility and enrollment processes. One strategy is for states to allow continuous 12-month eligibility for adults enrolled in the program. Allowing continuous eligibility would reduce churn in and out of the program and disruptions in care that could result. To implement 12-month eligibility, states will need to apply for a section 1115 waiver.

In addition, CMS and HRSA released a joint letter to state health officials and Medicaid Directors emphasizing the importance of coordination between state Medicaid programs and HIV/AIDS programs.

Guidance on 1115 Waivers

In a set of “Frequently Asked Questions,” CMS stated that given the ACA’s Medicaid expansion option, 1115 waivers that expand eligibility, but that institute caps on the number of people enrolled are prohibited. Because of the availability of the Medicaid expansion, such caps do not forward the objectives of the program, a requirement for section 1115 waiver approval. This guidance indicates that CMS will be changing the criteria it uses to review 1115 waiver proposals. In an ACA world, states may have to change the way they structure future state 1115 waiver proposals as well as current state 1115 waivers that will be up for renewal. More federal guidance is expected on this issue.

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CMS Health Care Innovation Award Grant Opportunity 
  • ACTION STEP: Assess whether HIV/AIDS and viral hepatitis programs or providers in your state may be eligible to apply for this grant to test models of care for people living with HIV and viral hepatitis.
CMS recently announced a funding opportunity for a new round of Health Care Innovation Awards of particular interest to HIV/AIDS and viral hepatitis programs and providers. Grants will be awarded to a range of eligible entities – including states, local governments, provider groups, and health systems – to test new payment and service delivery models that deliver higher quality, more cost-effective care to Medicare, Medicaid and CHIP beneficiaries.
Three categories of eligible projects are of particular relevance: 
  • Models that improve care for populations with specialized needs.
  • Models that improve the health of populations – defined geographically (health of a community), clinically (health of those with specific diseases) or by socioeconomic class – through activities focused on engaging beneficiaries, prevention (e.g.,  a diabetes prevention program or a hypertension prevention program), wellness and comprehensive care that extend beyond the clinical service delivery setting.
  • Models that test approaches for specific types of providers to transform their financial and clinical models.

The Funding Opportunity Announcement (FOA) lists HIV/AIDS as a priority area for these awards. CMS will accept letters of intent beginning June 3 until June 28, 2013 and will accept applications beginning June 14 until August 15, 2013. 

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ACA Enrollment Assistance Opportunities
  • ACTION STEP: Ensure that community health centers awarded outreach and enrollment grants are working with HIV/AIDS and viral hepatitis providers and reaching people living with and at risk for HIV and viral hepatitis. 
In April, HRSA announced the availability of approximately $150 million for community health centers to provide in-person enrollment assistance to help people enroll in ACA coverage. Applications were due May 31, 2013. This funding will allow community health centers to ramp up their application assistance staff to prepare for the influx of people who will be newly eligible for Medicaid and Marketplace coverage. Those awarded this grant are required to provide enrollment assistance in a culturally and linguistically appropriate manner and are required to demonstrate how they will meet the needs of underserved and vulnerable populations. This must include the ability to assist people living with HIV and viral hepatitis to enroll in coverage that meets their care and treatment needs.

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Guidance on 75/25 Waiver 
  • ACTION STEP: Review the guidance and assess use of a waiver as clients transition to public and private insurance coverage.
In May, HRSA announced a proposal to amend its procedure for application of a waiver from the requirement that programs spend 75 percent of Ryan White Program Parts A, B and C funds on core medical services. HRSA is proposing to allow more flexibility with regard to when grantees are able to apply for the waiver. The proposed process would allow grantees to apply for the waiver as part of their annual application, prior to submission of the application, or up to four months after their grant award.
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State Implementation Updates

States Begin to Publish Plan Premiums for Marketplace Coverage
  • ACTION STEP: Monitor information about the scope of coverage and costs of plans certified to be sold on Marketplaces to inform program and client transition planning. 
Over the past several months, several states have released information about the issuers that have applied to sell plans in the Marketplaces beginning in October, including the premiums plans intend to charge (e.g., California, Colorado, Oregon, and Washington). Some early analyses suggest that proposed premiums are lower than originally predicted. Over the coming weeks, state-run Marketplaces as well as CCIIO will review issuer submissions and approve plans for sale. As we move closer to open enrollment, it will be important to monitor state and federal announcements of plan offerings and to begin to assess scope of coverage and affordability to inform client transition plans and outreach and enrollment training.

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Health Department Planning Activities

Annual Meeting State Planning Highlights

At NASTAD’s recent annual meeting, Colorado, Tennessee, and Washington all shared various planning activities as they prepare programs, systems and clients for ACA implementation. Below are the highlights from these presentations: 
  • Colorado is in the process of developing a targeted transition plan for clients using current client income and coverage data to predict client eligibility for the Medicaid expansion or Marketplace coverage. Case managers will take a lead role in ensuring that assigned clients are appropriately transitioned as well as monitoring and reporting transition progress.
  • Tennessee is preparing to maximize access to private insurance through the Marketplace as a way to mitigate the Medicaid gap if the state does not expand Medicaid in 2014 (which at this point, looks unlikely). The state is working very closely with its ADAP insurance purchasing program to ramp up capacity and to develop a staggered plan for client transition to Marketplace coverage, beginning with clients enrolled in the PCIP who must transition by January 1, 2014.
  • Washington is working closely with its state Medicaid program to ensure a smooth transition of clients to Medicaid expansion coverage in 2014. Planning has included discussion of Medicaid managed care networks, scope of coverage and contract language.
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Assessing ADAP Income Criteria and Aligning with Modified Adjusted Gross Income (MAGI)

As ADAPs prepare systems for ACA implementation, many are considering aligning ADAP income criteria with ACA income criteria (MAGI). To assess the impact of using MAGI instead of current income criteria, ADAPs are taking a sample of clients and using the new MAGI methodology to determine impact (if any) on ADAP income eligibility. Several states that have conducted this analysis (e.g., Minnesota and Illinois) are transitioning to MAGI for ADAP income eligibility for the sake of administrative simplicity. 
NASTAD is always interested in hearing about specific state processes to prepare for health reform. Please contact Amy Killelea to share activities or specific documents that have been created. 
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Health Reform Resources
For questions or for suggestions for NASTAD health reform resources that would be helpful to your program, please contact Amy Killelea.

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