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 6, August 6, 2013
In the past month, the federal government has finalized several significant Affordable Care Act (ACA) regulations, including a much-awaited regulation with regard to the Medicaid expansion benefits requirements, giving the states the green light to move ahead with implementation. As open enrollment approaches in October, state HIV/AIDS and viral hepatitis programs are increasingly focused on preparing programs and clients for transition to new coverage options, including preparing case managers and identifying resources to help clients apply for Marketplace coverage. 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.
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.

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
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Health Reform Alerts

Last month, we introduced Health Reform Alert, a newsletter for state and territorial health department staff that provides brief and timely updates, analysis, and highlights on federal and state health reform activities. If you are subscribed to Health Reform Watch, you are automatically subscribed to Health Reform Alert. Below are the most recent issues:
Federal Implementation Updates

Final Medicaid Essential Health Benefits (EHB) Rule

  • ACTION STEP: Monitor your state’s public comment process for its State Plan Amendment proposal defining Medicaid expansion benefits, and be prepared to weigh in to ensure benefits meet HIV/AIDS and viral hepatitis care and treatment needs.
On July 5th, the Centers for Medicare and Medicaid Services (CMS) published the final rule with regard to the ACA Medicaid Essential Health Benefit requirements. The rule also finalized provisions governing Marketplace eligibility systems and coordination of consumer notices and appeals between Marketplaces and Medicaid.  The final rule covers a lot of technical ground, but the most relevant provisions for HIV/AIDS and viral hepatitis programs were highlighted in a recent NASTAD Health Reform Alert. Key take-aways from the rule include:
  • The final rule allows states to provide newly eligible Medicaid beneficiaries an “Alternative Benefits Package” (ABP) that includes the same ten categories of EHB as required in the private insurance market. This allows states to offer a Medicaid benefits package for the expansion population that could be very similar to the plan states chose as their benchmark plan for the private insurance market or could be very similar to the state’s traditional Medicaid benefits package. The rule does specify Medicaid-specific protections for prescription drugs, preventive services and protections for the “medically frail.”
  • The final rule clarifies the protections and requirements for states that implement a premium assistance program (where the state uses Medicaid funding to purchase private insurance through the Marketplace for Medicaid beneficiaries). Importantly, the rule clarifies that Medicaid beneficiaries may not be automatically enrolled into premium assistance programs.
  • The final rule adopts new cost-sharing rules for Medicaid (these new rules apply to both newly eligible and traditional Medicaid beneficiaries).  The most significant changes affect prescription drugs and non-emergency care sought in an emergency room.
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Certified Application Counselor Application Available
  • ACTION STEP: Encourage Ryan White Program providers who will be doing client outreach and enrollment to apply.
In July, the federal government announced the availability of an application for organizations to become Certified Application Counselors in the federally facilitated or partnership Marketplaces (state-based Marketplaces will develop their own application processes). Certified Application Counselors will help people apply for and enroll in Marketplace coverage after completing required training. However, there is no separate federal funding for these activities. To be eligible, entities must demonstrate the ability to provide services to help individuals obtain health care coverage and have experience in providing social services to the community – importantly, Ryan White providers as well as city, county, or municipal health departments are noted as examples of entities that may apply. For more information, see the following guidance letter published by the Centers for Medicare and Medicaid Services’ (CMS) Center for Consumer Information and Insurance Oversight (CCIIO).
In addition, HHS has launched a new ACA call center to address questions and help consumers and providers prepare for open enrollment. was also updated with new resources. Finally, HHS announced a list of community health centers throughout the country awarded $150 million to ramp up their enrollment assistance capacity. It is important to monitor ACA outreach and enrollment funding and training to ensure inclusion of information about HIV/AIDS and viral hepatitis programs.

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Supreme Court Decision on DOMA and Implications for ACA Eligibility 
  • ACTION STEP: If you are in a state that recognizes marriage equality for same-sex couples, make sure that married same-sex couples understand the federal definition of “household” and implications for ACA income eligibility.
In June, the Supreme Court issued a historic ruling, overturning a key section of the federal Defense of Marriage Act (DOMA).  Enacted in 1996, DOMA had limited the definition of marriage to a union between a man and a woman for the purposes of over a thousand federal laws, regulations, and programs. The Court’s decision striking down that provision means that same-sex couples that are legally married (in states that recognize same-sex marriages) will be entitled to the same treatment under federal law as opposite-sex married couples. The decision will have implications for the way that income eligibility is determined for federal programs – including ACA programs.  Income eligibility for the Medicaid expansion as well as subsidies to purchase private insurance through Marketplaces will be determined using Modified Adjusted Gross Income (MAGI), which is calculated using federal income tax returns. For people that file their taxes as married filing jointly, both incomes will be considered in determining income eligibility for ACA programs.

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Final Rule on “Minimum Essential Coverage” Definition
  • ACTION STEP: Ensure that clients understand their coverage choices and implications of coverage on eligibility for premium tax credits and cost-sharing reductions.
The federal government released a final rule and accompanying guidance, clarifying what counts as “minimum essential coverage.” Minimum essential coverage is relevant for the purposes of client eligibility for premium tax credits to purchase private insurance in the Marketplace as well as for applicability of the penalty for not having health insurance. Individuals must prove they do not currently have access to minimum essential coverage (in addition to meeting income and other eligibility criteria) to be eligible for premium tax credits to purchase private insurance through the Marketplace. For example, if a client is eligible for the following types of minimum essential coverage, he/she is NOT eligible for premium tax credits:
  • Government-sponsored health insurance (e.g., Medicaid and CHIP);
  • Comprehensive employer-sponsored health coverage that is affordable (meaning that the annual premium the employee must pay for self-only coverage is less than 9.5% of the employee’s annual household income and the plan offers a minimum set of benefits).
Of particular relevance to HIV/AIDS and viral hepatitis programs, the final rule clarifies that for the following coverage types, an individual is considered able to access minimum essential coverage (and is thus ineligible for premium tax credits) only if the individual is actually enrolled in the following coverage (NOTE: even if the individual is eligible for these coverage types, he/she must actually be enrolled to be ineligible for premium tax credits):
  • Medicare Part A requiring payment of premiums
  • State high risk pools
  • Student health plans
  • TRICARE programs
  • Veterans health programs
This means that clients eligible for, but not enrolled, in these coverage types are still eligible for premium tax credits to purchase insurance through the Marketplace.
Remember – individuals must also be enrolled in minimum essential coverage in order to avoid the penalty for not having insurance. In addition to the minimum essential coverage definition included in the statute (for the full list of what counts as minimum essential coverage, see IRS Q & A on ACA Shared Responsibility), the final rule clarifies that state high risk pools that offer coverage beyond December 2013 will count as minimum essential coverage (meaning that clients enrolled in state high risk pools will not be subject to the individual mandate penalty).
HIV/AIDS and viral hepatitis programs and case managers should be prepared to discuss coverage options with clients to ensure they are enrolling in the best coverage.

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Federal Delay of Employer Mandate Implementation
  • ACTION STEP: Monitor federal ACA implementation and additional guidance in the coming weeks and months.
In July, the Obama Administration announced a one-year delay in implementation of the ACA's employer mandate. The employer mandate requires large employers (those with 50 or more full-time employees) to offer affordable, minimum value health coverage to full-time employees. To incentivize employer compliance with this requirement, for each employee that receives a premium tax credit to purchase insurance through the Marketplace, the employer will be subject to a “shared responsibility payment.” The delay in implementation will allow employers and insurers additional time to comply with the new rules and put in place procedures for information reporting. While the practical, on-the-ground effects of the delay are likely not significant, the political implications are fueling continued opposition to ACA implementation.
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State Implementation Updates

States Continue 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 and request information from state departments of insurance.
Over the past several months, additional 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. State Refor(u)m has posted state issuer filing data where available. In states where the federal government is operating the Marketplace, the plan information has often been more difficult to obtain. Some health departments and advocates have been successful in requesting information about which issuers have submitted applications to sell products in the Marketplace from state departments of insurance. The Centers for Medicare and Medicaid Services’ (CMS) Center for Consumer Information and Insurance Oversight (CCIIO) has indicated that final plan information will not be publicly announced for federally facilitated Marketplaces until September.

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States Ramp up Consumer Education and Outreach Campaigns
  • ACTION STEP: Monitor state plans for Patient Navigator programs and other insurance assister and certified application counselor programs to ensure HIV/AIDS and viral hepatitis programs are included.
As the federal government releases new ACA outreach and enrollment funding and training initiatives, states are also ramping up their own consumer education and outreach campaigns. Kentucky has released a request for proposals (RFP) for in person assisters. Colorado, Nevada, and Washington and, Illinois have all announced their selections for in-person assisters, several of which include HIV/AIDS programs and providers. In addition, private organizations such as Enroll America are developing state campaigns for outreach and enrollment efforts and are developing resources that could be helpful for state HIV/AIDS and viral hepatitis programs and providers.

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Health Department Planning Activities

Modified Adjusted Gross Income (MAGI) Conversion

As ADAPs prepare systems for ACA implementation, many are considering aligning ADAP income criteria with ACA income criteria (MAGI). In assessing whether this alignment makes sense, states have compared MAGI criteria with ADAP income criteria to assess impact. In states that have moved forward with MAGI conversion, administrative simplicity and ease of coordination of ACA coverage options was the driving factor behind the shift. Illinois is transitioning its income criteria to MAGI, and has developed the following materials to explain these changes to ADAP case managers and clients:
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Client Education Resources

Many state HIV/AIDS and viral hepatitis programs are beginning to develop client education resources to explain ACA coverage options and related program changes. Florida has released this client information flyer on preparing for ACA implementation. It details action steps that clients should take and educational resources. It will also be produced in Spanish and Creole.
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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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