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Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers


April 18th, 2014
by Timothy Jost

On February 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges. This significantly exceeds the White House’s original goal of 7 million enrollees. It is far more than the Congressional Budget Office’s recent projections of 6 million.

The number of actual enrollees will be smaller than this number. The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year. To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year. In the end, 6 to 7 million average enrollees is probably a reasonable estimate.

This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act. The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA. This number is probably high, but it is clear that the ACA has dramatically increased coverage of Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still).

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Four Years Into A Commercial ACO For CalPERS: Substantial Savings And Lessons Learned


April 17th, 2014
 
by Glenn Melnick and Lois Green

Editor’s note: In addition to Glenn Melnick, this post is coauthored by Lois Green.

Background: In a very short period of time, Accountable Care Organizations (ACOs) have become an important and widespread part of the US health care landscape. A recent Health Affairs Blog post estimates the total number of public (Medicare) and private ACOs at more than 600 nationally, covering more than 18 million insured population. Despite their rapid and widespread adoption, relatively little is known about how ACOs actually work and how successful they have been. This is due in part to their relative “newness,” as many reported ACOs are just getting up and running. Others have been operational for short periods of time and have yet to produce meaningful or long-term sustainable results.

This Health Affairs Blog post helps fill some of this void by reporting on the operational experiences of one of the oldest (4+ years) and largest commercial ACOs in the nation. A previous Health Affairs Blog post reported on its initial planning and start-up phase, and a subsequent Health Affairs article reported on its early financial results.

In 2007, Blue Shield of California, along with provider and employer partner organizations, began exploring development of one of the first ACO-like programs in the country to serve Commercial patients. It launched in 2010 and, as reported below, has been generating savings to consumers throughout the period. Located in the competitive Sacramento market of northern California, the ACO is an example of an innovative shared savings model involving a large insurer—Blue Shield of California; a purchaser—the California Public Employees Retirement System (CalPERS); a physician group—Hill Physicians Medical Group (HPMG); and a hospital system—Dignity Health. The population served approximately 42,000 CalPERS employees and their families covered by Blue Shield.

In this Health Affairs Blog interview, senior executives from each of the partnership organizations, all of whom have operational responsibilities and oversight of this ground-breaking Commercial ACO, discuss key operational aspects of the ACO and its implementation. They discuss evolution of the culture, governance and essential “partnership” relationships an ACO requires to survive and thrive. In addition, they detail specific operational initiatives designed to coordinate and manage care, and report on how these initiatives have fared over the four-year period since the ACO’s launch. Empirical results show success in many areas, with challenges in some others. Of particular note has been overall cost of health care (COHC) savings reported at gross savings of more than $105 million, with net savings of $95 million to CalPERS members, since 2010. Finally, the partners illuminate the ACO’s future directions and offer lessons for other organizations considering development of an ACO delivery system for the Commercial market.

The interview was supported by funding from the California HealthCare Foundation.

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We’ll Need A Bigger Boat: Reimagining The Hospital-Physician Partnership


April 17th, 2014
 
by Francis J. Crosson and John Combes

Editor’s note: In addition to Francis J. Crosson, this post is coauthored by John Combes.

Change is underway in the delivery and financing of American health care, and it is manifested in the evolving relationship of hospitals and physicians across the U.S. These developments are most striking in California, but are appearing in various forms in almost all states. Physicians and hospitals are being both “pushed” and “pulled” together in new ways by a variety of market forces, including the development of Accountable Care Organizations (ACOs) for both Medicare and commercially insured patients, increased direct employment of physicians by hospitals, the emergence of new payment mechanisms such as global payments, and, in general, by the need for physicians, physician groups and hospitals to deliver greater “value.”

All of this presents the opportunity to redesign care to be more coordinated, efficient, patient-driven, and effective. These integration forces could lead to the kind of organizations envisioned 15 years ago in the Institute of Medicine report “Crossing the Quality Chasm”, resulting in the Triple Aim of better health, better patient care experiences and outcomes, and improved affordability — driven, in part, by new patient care models and payment methods including incentives for improving the value of health care services.

Many physicians are uncomfortable with the idea of physician-hospital integration for several reasons. The long tradition of “professional autonomy”– perhaps best described as “the need for physicians to be able to make appropriate and scientifically based patient-by-patient decisions in the best interest of those patients” — can raise fears among some physicians about becoming part of a larger practice or institution and losing that autonomy. Additionally, some physician groups have shown that they can develop a successful ACO without the need for hospital and insurance partners, preferring to manage the clinical and financial risk alone.

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Look At Consequences Of Rejecting Medicaid Expansion Leads First Quarter Health Affairs Blog Most-Read List


April 14th, 2014
by Tracy Gnadinger

Given their recent mention in Paul Krugman’s New York Times‘ column, it’s not surprising that Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler‘s discussion of the health and financial impacts of opting out of Medicaid expansion was the most-read Health Affairs Blog post from January 1 to March 31, 2014.

Next on the list was Robert York, Kenneth Kaufman, and Mark Grube‘s discussion of a regional study on the transformation from inpatient-centered care to an outpatient model focused on community-based care. This was followed by Susan Devore‘s commentary on changing health care trends and David Muhlestein‘s evaluation of accountable care organization growth.

Tim Jost is also listed four times for contributions to his Implementing Health Reform series on Medicaid asset rules, CMS letter to issuers, contraceptive coverage, and exchange and insurance market standards.

The full list appears below.

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Implementing Health Reform: Changing Focus, And Changing Leadership, At HHS (Updated)


April 11th, 2014
by Timothy Jost

With the March 31, 2014 deadline for applying for qualified health plan coverage through the health insurance exchanges behind us, and the April 15, 2014 deadline for completing those applications upon us, Affordable Care Act implementation has quieted considerably. The Centers for Medicare and Medicaid Services have been very active on the Medicare front, releasing in recent days their 2015 Medicare Advantage Rate Announcement and Call Letter and publishing data on Medicare payments to 880,000 Medicare providers. But on the exchange and insurance market reform side, CMS has only one major proposed rule pending at this time, the Exchange and Insurance Market Standards Rule proposed in March, and nothing pending for regulatory review at the Office of Management and Budget.

I am unaware of any major regulatory issuances expected in the immediate future from the Departments of Treasury or Labor, although Treasury does have a number of proposed rules on the table that have yet to be finalized dealing with issues such as minimum value of employer coverage or premium tax credit reporting requirements for exchanges.

On April 10, the media reported two major Health and Human Services developments. First, Secretary of Health and Human Services Kathleen Sebelius announced at a Senate Hearing that 7.5 million Americans have now signed up for health plans through the exchanges. Although opponents of the ACA continue to quibble about how many of these individuals have actually paid their premiums and how many were uninsured previously, the number far exceeds earlier estimates of how many would enroll in health insurance through the exchanges. A recently released Rand survey, which does not fully take into account the late surge that increased exchange enrollment by over 70 percent in the last month, indicates that in fact the ACA has made a significant dent in the number of uninsured in the United States.

The second announcement was of the resignation of Secretary Sebelius herself, and of the nomination of Sylvia Mathews Burwell as her replacement.

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Implementing Health Reform: Medicaid & CHIP February 2014 Report


April 5th, 2014
by Timothy Jost

On April 4, 2014, the Centers for Medicare and Medicaid Services released their Medicaid & CHIP February 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report. (Blog post here.) For the first time, the February monthly report provides meaningful data on enrollment.

Like previous reports, the report gives the total number of applications received by all reporting state agencies (2,207,513) and total number of individuals determined eligible for Medicaid and CHIP by state agencies (2,249,120). For comparison, the numbers of applications is down from initial January reports (2,266,778), but the number of determinations is up (2,436,879).

As with previous reports, however, these numbers are subject to so many qualifications as to be little use for determining growth of the Medicaid program. The data do not include numbers from New York and Washington, while Tennessee only reported CHIP data. They are also very preliminary — the January determinations figure was revised upwards by about a fifth in February.

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What The Affordable Care Act Means For Pregnant Inmates


April 4th, 2014
 
by Katy Kozhimannil and Rebecca Shlafer

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

The Affordable Care Act (ACA) is anticipated to expand coverage to 44 million Americans. As John Iglehart noted in his introduction to the March issue of Health Affairs, expansion of Medicaid through the ACA will open an important door for a particularly vulnerable population – those who are cycling in and out of the criminal justice system.

Although Medicaid does not cover standard health care for inmates during incarceration, expansion of Medicaid to single and childless adults has meant that prisons and jails can start enrolling inmates (a substantial portion whom meet these criteria) so they are covered upon release.

The ACA also allows Medicaid to pay for inmates’ care for hospital stays longer than 24 hours. Such changes have important implications for a group of inmates that is not often the focus of health policy dialogue – incarcerated pregnant women.

A Particularly Vulnerable and Costly Group: Pregnant Prisoners

Nationwide, 75 percent of incarcerated women are of reproductive age, and about 6-10 percent of female prisoners are pregnant during their incarceration. Incarcerated women fare worse than incarcerated men, and their reproductive health care needs, including access to contraception and abortion services, often go unmet. Inmates who are pregnant face additional risks. Compared with similar women that are not incarcerated, pregnant inmates have more risk factors and worse birth outcomes, for both mothers and babies.

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The Payment Reform Landscape: Price Transparency


April 2nd, 2014
by Suzanne Delbanco

Editor’s note: This is the third post in a Health Affairs Blog series on payment reform by Catalyst for Payment Reform Executive Director Suzanne Delbanco. The first two posts are available here and here.

Last week Catalyst for Payment Reform (CPR) and our partners at the Healthcare Incentives Improvement Institute (HCI3) released our second annual Report Card on State Price Transparency Laws. This year, we decided not to grade states on a curve and to place greater emphasis on the price information actually available to consumers—not just what is written in the law.

Forty-five states received an F in this year’s Report Card, but there were a couple of notable exceptions: Massachusetts and Maine. Each month in this blog, I’ve been sharing insights about payment reform and which models are proving to work, so this naturally raises the question: what is the relationship between payment reform and the success of state price transparency efforts?

At CPR, we like to say price transparency is one of the core building blocks of payment reform and a higher-value health care system. Purchasers and consumers need transparency for three primary reasons: (1) to help contain health care costs; (2) to inform consumers’ health care decisions as they assume greater financial responsibility; and, (3) to reduce unknown and unwarranted price variation in the system.

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Embarking On A New Journey With Health Affairs


March 31st, 2014
by Alan Weil

I am delighted to be taking on the role of editor-in-chief of Health Affairs. This is a dynamic time in all aspects of health and health care: insurance coverage expansions, delivery system changes, and growing attention to population health.  Building upon thirty-three years of peer-reviewed scholarship, Health Affairs will continue to serve as the nation’s primary resource for the health policy community.

My goals for Health Affairs coalesce around a single theme: broadening the reach of the journal.

Health Affairs is strong in the core health policy community, but our scholarship is relevant to myriad actors in the one-sixth of the United States economy represented by health care.  My goal is to broaden our engagement with the worlds of law, finance, design, and many others.

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Health Policy Leader Alan Weil To Become New Health Affairs Editor-in-Chief


March 31st, 2014
by Chris Fleming

Health Affairs and its publisher Project HOPE are pleased to announce that Alan Weil will become the journal’s new editor-in-chief on June 2, 2014.

Weil, a highly respected expert in health policy and current member of Health Affairs’ editorial board, will lead the journal after serving as the executive director of the National Academy for State Health Policy (NASHP) since 2004. His work with state policymakers of both political parties put Weil at the forefront of health reform policy, implementation, innovation, and practice. Prior to his leadership of NASHP, he served in both the public and private sectors. He directed the Urban Institute’s “Assessing New Federalism” project; served as the executive director of the Colorado Department of Health Care Policy and Financing and a health policy advisor to Colorado’s then-governor, Roy Romer; and was the assistant general counsel in the Massachusetts Department of Medical Security.

“We’re delighted to welcome Alan to the Project HOPE family,” said John P. Howe III, M.D., President and CEO of Project HOPE. “He comes to Health Affairs with more than 24 years of experience in health policy development and a stellar record of leadership and innovation in this field. I’m confident he will lead the journal’s talented staff on a new and successful path forward. I am extremely grateful to John Iglehart, the Founding Editor of Health Affairs for his stewardship of the journal for more than 25 years, ensuring its coveted rank as the leading health policy journal of our time.”

“Alan Weil’s extensive background in health and health care policy will serve him well in his new role as Health Affairs’ editor-in-chief,” noted John Iglehart, who currently leads the journal. “With his position on the front lines of health system change, he is an experienced leader who has deep familiarity with and longstanding connections to the health policy, research, and health care leadership communities. In particular, in his role as NASHP’s executive director, Alan worked on complex issues of critical importance to leaders in state and federal government and the private sector. This background will serve Health Affairs well as it continues to grow in influence both in the US and globally.”

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Exhibit Of The Month: More HIV Testing With Medicaid Expansion


March 28th, 2014
by Tracy Gnadinger

Editor’s note: This is the second post in the new “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This month’s exhibit examines the potential impact of the Affordable Care Act’s Medicaid expansion on HIV testing from 2013-2017, comparing a nationwide eligibility expansion with one limited to the eighteen states that had committed to expansion as of July 2013.

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A March Madness Health Wonk Review


March 27th, 2014
by Chris Fleming

Welcome to the “March Madness” edition of the Health Wonk Review. The NCAA college basketball tournament seemed like a natural theme for a health care policy blog post: huge amounts of money floating around in ways that only sometimes correlate with performance, and head-to-head match-ups that can yield results no one expected (though in the tournament those unexpected results produce quicker and more certain changes than is often the case in health care).

We considered illustrating each blog post with pictures of a college basketball team from the author’s home state celebrating a championship, but we thought better of that after seeing this cautionary tale. So let’s get to the great collection of posts from our Wonkers.

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Implementing Health Reform: Additional Enrollment Opportunities And ACA Litigation (Updated)


March 26th, 2014
by Timothy Jost

On March 26, 2014, the Centers for Medicare and Medicaid Services drew the 2014 open enrollment period toward a close with a flourish, releasing a series of guidance documents regarding opportunities that remain to enroll in coverage after the open enrollment period. The Department of the Treasury also released a guidance, a fact sheet, and letter addressing the situation of domestic violence victims who apply for premium tax credits but are unable to file taxes jointly, as generally required by the ACA.

Extended Enrollment Opportunities

The first CMS Guidance addresses the situation of people waiting “in line” for enrollment in the federally facilitated marketplace or exchange (FFM) on the final day of the 2014 open enrollment period, March 31. CMS anticipates that application traffic will be very high during the last week of open enrollment—over a million individuals visited healthcare.gov on Monday, March 24. Individuals who applied by March 31, but did not complete their application, will be allowed to complete it—effectively given a special enrollment period to finish enrolling. CMS does not specify how long consumers may continue to do so beyond saying that they will have a “limited amount of additional time.” If applicants pay their first month’s premium by the time required by their insurer, they will be able to being coverage on May 1.

Paper applications that are received by April 7, or that were filed by March 31 but uncompleted because they were pending submission or review of documents, can also be approved for coverage beginning May 1 for consumers who choose a plan by April 30. Consumers who take advantage of this special enrollment period may also apply for a hardship exemption to avoid paying the individual responsibility tax for the additional month they are uninsured. The guidance applies only to the FFM, but it clarifies that state based marketplaces can apply similar policies.

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Health Insurance Coverage Is Just The First Step: Findings From Massachusetts


March 26th, 2014

As the rollout of coverage expansions under the Affordable Care Act (ACA) continues across the country, more Americans are gaining insurance coverage, with all the benefits that that implies in terms of health care access and financial protections. However, if, as President Obama has argued, affordable health care is a cornerstone of economic security for American families, findings from a survey of Massachusetts residents suggest that insurance coverage alone will not be enough.

Since its 2006 health reform initiative, Massachusetts has had the nation’s highest level of insurance coverage. But though there have been improvements in access to health care and health care affordability, insurance coverage has not eliminated the burden of high health care costs for Massachusetts families.

Health care costs are a problem for many insured adults. In 2012, more than one-third (38.7 percent) of Massachusetts adults with health insurance coverage for all of the past year reported problems with health care costs, with the level much higher for low-income insured adults (41.6 percent for those with family income at or below 138 percent of the poverty line—the income eligibility standard for the Medicaid expansion under the ACA) and middle-income insured adults (49.5 percent for those with income from 139 to 399 percent of poverty—the income group targeted by the new health insurance Marketplaces). Insured adults in Massachusetts report going without needed health care, cutting back on other spending, reducing savings, and taking on debt to deal with health care costs.

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Health Information Exchange In NYC Jails: Early Policy Challenges


March 20th, 2014
by Michelle Martelle

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health. For more on jails and health information technology in particular, see here, here, and here.

New York City has the second largest jail system in the United States, with an average daily census of approximately 12,000 and 80,000 annual admissions. It is well documented that the population that cycles in and out of US jails each year is statistically sicker than the general population and therefore would benefit from greater care coordination between correctional and community settings. The Department of Health and Mental Hygiene’s Bureau of Correctional Health Services (CHS) is responsible for the care delivered in all 12 NYC jail facilities. The mission of CHS is to provide a community standard of care based on three core frameworks; patient safety, population health and human rights.

As part of this mission, CHS implemented a full electronic health record (EHR) system starting in 2008, completing the implementation of the final facility in 2011. One of the most promising features of EHRs is the ability to share information electronically to facilitate care coordination, referred to as Health Information Exchange (HIE).  Preliminary research of the use of HIE in community based settings is encouraging, with the use of HIE in the Emergency Department resulting in 30 percent fewer admissions and use in ambulatory settings resulting in 56 percent fewer readmissions within 30 days of hospital discharge. (Results pending review; presented 11/14/13 at NYeC Digital Health Conference by Center for Healthcare Informatics and Policy (CHiP).) In the hopes of realizing the full benefits of its EHR system, CHS recently launched an HIE pilot in its women’s facility.

The goals of integrating HIE into jail-based health care are to inform the care patients receive while incarcerated and to coordinate care upon release.  Currently, CHS has access to two external sources of information: BHIX, a Regional Health Information Organization (RHIO) that recently merged with Healthix and now includes patient data from some major hospital systems and community providers in parts of Brooklyn, Queens and Long Island; and PSYCKES, a Medicaid claims-based data warehouse that includes claims information (both medical and mental health) on patients who have had a substance abuse or mental health diagnosis and/or substance abuse or mental health treatment within the last five years.

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The Arkansas Payment Reform Laboratory


March 18th, 2014

Editor’s note: This post is the first in a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Arkansas model.

In 1932, Supreme Court Justice Louis Brandeis famously described states as laboratories of democracy. The idea that states can try “novel social and economic experiments without risk to the rest of the country” is certainly relevant today as the United States reforms its health care system. Many states are developing novel strategies.  Arkansas is one, adopting an innovative model of delivering and financing health care.

The Arkansas transformation model, known as the Arkansas Payment Improvement Initiative (APII), aims to create payment incentives that motivate and reward patient centered management of outcomes and reductions in total cost of care. The payment model relies on several types of reforms, including payments based on “episodes of care” and incentives surrounding Patient Centered Medical Homes for health needs and Health Homes for populations with additional, more complex support needs. In this post, we focus on the episodic payment component. Arkansas’s system is a multi-payer model, with participation by Medicaid, the self-insured State Employee and Public School Employee health insurance plans and the two largest insurers in the state, Arkansas Blue Cross and Blue Shield (ABCBS) and QualChoice of Arkansas (QCA), as well as Walmart, the state’s largest private self-insured employer purchaser.

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Implementing Health Reform: Exchange And Insurance Market Standards Proposed Rule


March 16th, 2014
by Timothy Jost

On March 14, 2014, the Department of Health and Human Services, Centers for Medicare and Medicaid Services, published a proposed rule titled “Patient Protection and Affordable Care Act: Exchange and Insurance Market Standards.” The rule was accompanied by a bulletin on product discontinuance, one of the issues addressed by the rule. The proposed rule was one of a number of March 14 ACA issuances, the rest of which were addressed in earlier posts.

The Exchange and Insurance Market Standards proposed rule addresses a grab bag of issues that all relate loosely to exchanges or to the ACA’s insurance market reforms. Some of these — like QHP quality reporting — are issues that HHS had failed to address earlier because these issues did not rise to the urgency of other issues that needed to be resolved immediately for health reform to proceed. Others — like regulation of navigators — are issues that had been addressed earlier, but where it has become apparent that mid-course corrections are necessary. Still others, like modifications in the premium stabilization programs, are issues that have arisen in the unfolding course of events as problems developed in implementation.

Most of the issues are largely unrelated to one another; thus this description of the rule will proceed like the rule itself, addressing seriatim a catalog of largely unrelated issues. (A list of topics addressed by the rule is included in a note at the end of this post.)

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Implementing Health Reform: Ryan White Third-Party Payments, 2015 Letter To Issuers, And Other ACA Developments


March 15th, 2014
by Timothy Jost

On March 14, 2014, the Department of Health and Human Services released a flood of regulations, proposed regulations, and guidance addressing a host of Affordable Care Act implementation issues. From all indications, HHS has cleared the decks of all the regulatory issuances it had under consideration– nothing involving ACA implementation remains pending at the Office of Management and Budget. Perhaps someone made a promise that all would be completed by the end of the winter (or by Saint Patrick’s Day). More likely the necessity of having the ground rules for 2015 in place so that insurers could proceed with their 2015 forms and rates, and states with approving them, drove the deluge. In any event, it will take several posts to cover it all.

Yesterday’s post covered a notice on extending the federal preexisting condition high risk pool and a frequently asked questions document on coverage of same-sex spouses. The Internal Revenue Service also released a set of general Tax Tips for Same-Sex Couples (which covers general tax information and will not be discussed here), while HHS issued a blog post summarizing its frequently asked questions document.

This post will cover several other issuances released late in the day on March 14, 2014. These include an interim final rule (with comment period) dealing with third party payments for qualified health plans (QHPs) and stand-alone dental plans (SADPs); the 2015 final annual letter to issuers in the federally facilitated marketplace; a set of frequently asked questions on retroactive coverage, and a set of frequently asked questions on the use of exchange grants and no-cost extensions.

A final post will examine a proposed rule on exchange and insurance standards for 2015 and beyond and an accompanying bulletin on product discontinuance.

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Implementing Health Reform: The 2015 Health Insurance Marketplace Blueprints And More ACA News


March 14th, 2014
by Timothy Jost

In its final 2015 Notice of Benefit and Payment Parameters, the Centers for Medicare and Medicaid Services (CMS) noted that state applications to operate exchanges for 2015 would be due on June 30, 2014. On March 7, 2014, CMS released at its Paperwork Reduction Act (PRA) website the blueprints that states are to use to apply to operate an exchange (called a marketplace in the blueprint). The PRA listing also includes a helpful crosswalk between the proposed and final blueprint.

This post discusses these blueprints as well as other news related to Affordable Care Act implementation, such as an additional one-month extension of coverage in the federal Preexisting Condition High Risk Pool.

The biggest change in the 2015 blueprint is that plan management state partnership exchanges are no longer available. States that decide to assist in plan management functions will do so on an ad hoc basis and are not required to file a blueprint. This change apparently recognizes the reality that many of the states assisting in plan management are not able politically to identify themselves as partners, and thus there is little point in requiring some to do so and not others. States do also not need to file a blueprint regarding their decision on whether to use the federal exchange to assess or determine Medicaid eligibility.

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Continuous Coverage Improves Costs And Quality For Children And Low-Income Adults


March 13th, 2014
by Paul Cotton

The termination of Medicaid and Children’s Health Insurance Program (CHIP) coverage due to short-term income changes or frequent reapplication requirements increases overall health care costs and negatively affects quality of care and quality measurement and improvement efforts. This may have a significant yet commonly overlooked impact on income-related health care disparities. By requiring at least twelve months of continuous coverage, we could prevent avoidable complications, reduce administrative burden, improve quality measurement and improvements efforts, and ultimately, reduce costs.

Current Medicaid Coverage Costs

One year of continuous adult Medicaid coverage costs, on average, 22 percent less per month than six months of coverage, and 42 percent less than just one month of coverage. That is because people who lose coverage have more emergency room visits, hospital admissions, and preventable problems such as the onset of asthma and diabetes; they also have more problems that could have been managed with ambulatory care and lower rates of cancer screening and early detection. Current re-enrollment requirements also contribute to additional administrative costs that will increase as people toggle back and forth between Medicaid/CHIP and the individual health insurance exchanges.

Less than twelve months of coverage also directly harms quality measurement and improvement efforts. Because accurate measurement requires at least twelve months of coverage, those with shorter coverage periods are excluded from performance evaluation. Most Healthcare Effectiveness Data & Information Set (HEDIS is a registered trademark of NCQA) measures, for example, require evaluation of at least twelve months of claims or record reviews to ascertain whether appropriate services were provided in a timely manner. As a result, plans and providers may not have enough people on which to report and do not get credit for high quality.

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