Implementation efforts continue as the federal government releases new guidance.

Health Reform Watch

Volume 11, March 6, 2014
Implementation efforts continued as the federal government released new guidance regarding the Pre-existing Condition Insurance Plan (PCIP) transition, treatment of Medicaid Medically Needy/Spend Down programs, and proposed guidance to Qualified Health Plan (QHP) issuers planning to sell products in 2015. The most recent federal and state updates as well as health department implementation highlights are discussed in detail below.
NASTAD is always interested in hearing about specific state processes to prepare for health reform. Please contact Amy Killelea or Xavior Robinson to share activities or specific documents that have been created. We are in the process of creating a webpage to better share these documents.

In This Edition


From the NASTAD Blog: The Most Recent Health Reform Posts

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AIDS Drug Assistance Program (ADAP) Alerts

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Federal Implementation Updates

Center for Consumer Information and Insurance Oversight (CCIIO) Seeks Comments on 2015 Letter to Issuers
  • ACTION STEP: Monitor plan compliance with CCIIO Requirements and Provide NASTAD with comments

On February 3, CCIIO released a draft of its 2015 letter to issuers. The letter offers administrative guidance and a timeline for certification to insurance companies that intend to offer QHPs in the federally-facilitated and small business help options program marketplaces in 2015. The letter focused on a number of issues pertinent to people living with HIV and viral hepatitis, including:

  • Stronger network adequacy standards as they relate to essential community providers (ECPs). Insurance companies that intend to offer QHPs must demonstrate that they have contracts with at least 30% of the ECPs in their respective service areas. This must include at least one provider in each of the six ECP categories for each county in the service area. Ryan White providers are one of the six ECP categories:
    • Federally-qualified health centers
    • Ryan White providers
    • Family planning providers
    • Indian health providers
    • Specified hospitals including disproportionate share hospitals (DSH) and DSH-eligible hospitals, children’s hospitals, rural referral centers, sole community hospitals, free-standing cancer centers, and critical access hospitals
    • Other ECP providers, including STD clinics, TB clinics, and other entities that serve predominantly low-income medically, underserved individuals
  • Greater transparency requirements with regard to QHP information, including publication of provider networks and formularies in a way that is accurate, easy to find, and sufficiently detailed to allow consumers to make an informed decision when picking a plan.
  • Guidance on non-discriminatory benefit designs and market-wide consumer protections that apply inside and outside of marketplaces.
    • CMS intends to propose rules on reviews of prescription drugs based on clinical appropriateness that states will have the option to implement.
If you have comments regarding the 2015 draft letter to issuers, please contact Xavior Robinson

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IRS Issues a Proposed Rule and a Notice on Minimum Essential Coverage and Medicaid

  • ACTION STEP: Ensure that clients are aware of and compliant with minimum essential coverage standards

The IRS has released guidance that aims to provide relief of shared responsibility payments for Medicaid beneficiaries.
The proposed rule would exempt beneficiaries enrolled in limited benefit Medicaid programs (including Medically Needy and Spend-down programs) from individual shared responsibility payments that people must pay if they do not comply with the minimum essential health insurance coverage. This means that those individuals who would have qualified for limited Medicaid may apply for subsidies to purchase QHPs in the Marketplace instead. This notice ensures that all Medicaid beneficiaries are exempted from shared responsibility payments.

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CCIIO Offers Guidance on PCIP Extension and Premium Payments

  • ACTION STEP: Ensure that there is no overpayment of PCIP premiums, especially for coverage after the program ends on March 31

On January 15, CCIIO issued guidance formally extending PCIP coverage to the end of March 2014 and flagging specific issues regarding third-party payments during the PCIP transition. Highlights include:

  • Third-party payers of PCIP premiums (including ADAP) should continue to assist eligible enrollees in enrolling in a QHP through a marketplace;
  • PCIP enrollees have been mailed a letter advising them that their coverage will terminate on March 31, 2014;
  • Premium payments for coverage of PCIP enrollees must be received no later than February 14 for the February premium, and by no later than March 5 for the March premium. The premium payment will remain the same as the December 2013 premium

CCIIO is also urging programs to carefully track payments for PCIP clients to ensure that no overpayments occur (i.e., payments made for coverage after PCIP ends on March 31, 2014). There will be no way for ADAPs to recoup overpayments made to the PCIP payment center after coverage ends.

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CCIIO Offers Guidance on Switching Plans During Open Enrollment

  • ACTION STEP: Ensure that clients are enrolled in an appropriate plan by March 31, 2014

On February 6, CCIIO issued guidance allowing consumers to switch QHPs during the initial open enrollment period. Four conditions must be met: 1) individuals have to switch to a plan offered by the same issuer; 2) the plan has to be offered at the same metal level (bronze, silver, gold, etc.) and the same cost-sharing reduction level; 3) the change must be because of a limited provider network; and 4) consumers must request the change during the open enrollment period. The guidance also notes that consumers may switch plans outside of the open enrollment period if they qualify for a special enrollment period (including if consumers were given inaccurate information about the benefits covered through glitches that caused to display inaccurate information or because of inaccurate or incomplete information provided by issuers). 

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3.3 Million Individuals Sign Up for QHPs in Marketplaces

  • ACTION STEP: Sustain outreach and enrollment activities to people living with HIV and viral hepatitis

On February 12, the Department of Health and Human Services released the latest QHP enrollment data. Nearly 3.3 million individuals have signed up for QHP coverage, with 1.9 million and 1.4 million enrollments in the federally-facilitated and state-based marketplaces respectively. Of note, there was a 53 percent increase in plan selections in January. ACA education, outreach, and enrollment efforts will continue over the coming months in order to maximize QHP enrollment by the March 31 deadline (people eligible for Medicaid may enroll at any time during the year).

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Medicaid Expansion Update

  • ACTION STEP: Monitor and participate in state Medicaid planning to ensure that Medicaid expansion plans meet the affordability, care, and treatment needs of people living with HIV and viral hepatitis

On January 22, CMS issued a report finding that more than 6.3 million beneficiaries renewed or signed up for Medicaid or State Children’s Health Insurance Programs (SCHIP) coverage between October 1 and December 31 of 2013. The report also noted that nearly 2.3 million new beneficiaries were determined to be eligible in November alone. A report by Avalere Health estimated that of the 6.3 million beneficiaries, between 1 and 1.8 million are attributable to the ACA. This means that most of the new enrollees were eligible for Medicaid under pre-ACA rules, but had never enrolled in the program. The table below details November’s Medicaid and SCHIP data by state expansion status.

New Medicaid Beneficiaries in November 2013

The movement to expand Medicaid under the ACA in every state is ongoing and a moving target. The map below indicates Medicaid expansion and marketplace status by state.

Update: Medicaid Expansion Map

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State Implementation Updates

Advocates Urge Federal Action to Require QHPs to Accept Premium Payments from the Ryan White Program/ADAP

  • ACTION STEP: Monitor QHP policies with regard to third-party payments in your state; sustain efforts to enroll eligible ADAP clients into QHPs

Issuers in two states – Blue Cross and Blue Shield products in Louisiana and North Dakota – have prohibited the acceptance of premium payments from ADAP on behalf of eligible clients. There are a number of federal and state advocacy efforts underway around this issue, including a recent federal complaint filed against Blue Cross and Blue Shield of Louisiana by Lambda Legal and AIDSLaw of Louisiana. On February 7, the Centers for Medicare and Medicaid Services (CMS) issued updated guidance clarifying that Qualified Health Plans are allowed to accept premium payments from the Ryan White Program/ADAP, and encouraging them to do so. NASTAD is working with our federal coalition partners to urge CMS to also issue an explicit requirement that issuers accept premium payments from the Ryan White Program/ADAP. Please email Xavior Robinson, if you are aware of other third-party payment barriers.

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Health Department Updates

NASTAD Convenes Prevention and Health Equity Meetings to Discuss the Changing Health Care Landscape

Gay Men’s Health Equity Work Group

On January 23-24, 2014, NASTAD’s Gay Men’s Health Equity Work Group convened to exchange ideas with regard to the role of state health departments in addressing barriers to the optimal care and treatment of gay men. More than 30 public health professionals attended the meeting, which placed particular emphasis on ACA outreach and enrollment, prevention modalities for gay men and other men who have sex with men (MSM) that are HIV negative, leadership development and mentoring, and partnerships with businesses and Internet sites that cater to gay men. Take a look at CONCEPTS: A Health Department Response to the HIV, STD, and Viral Hepatitis Epidemics Among Gay Men/MSM in the United States to review a collection of activities that state health departments are currently implementing to meet the public health challenges facing gay men/MSM. 

ACA Prevention Meetings

NASTAD convened two meetings focused on HIV prevention and the ACA held in Washington, DC and Sacramento,CA on January 9-10 and January 28-29 respectively. The meetings focused on the impact that the demands of the ACA and prevention funding constraints have on the HIV prevention programs of state health departments and opportunities for leveraging ACA initiatives and programs to increase public and private insurance coverage for prevention services. The meeting sessions focused on partnerships of community-based organizations with medical providers, opportunities to develop and enhance reimbursement of preventative services, opportunities for collaboration among public health programs (including HIV, STD, viral hepatitis, family planning, immunization, and TB) in a changing health care landscape. For a look at how health departments are accelerating HIV prevention and care in the United States, check out the recently released Raising the Bars report and policy agenda

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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 or Xavior Robinson.

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