Balance billing – a new report on recent efforts by state

PCG subject matter experts recently completed a survey report entitled “Balance Billing: Report of Recent Efforts to Protect Consumers.” The practice of balance billing is historically commonplace, but increased scrutiny on rising out of pocket health care costs is driving efforts to provide greater transparency into the practice.

For those states contemplating crafting consumer balance billing protections, this paper aims to provide a landscape of the options available, with national models from organizations like the National Association of Insurance Commissioners and the National Conference of Insurance Legislators outlined. Additionally, our report includes a comprehensive list that outlines enacted and pending balance billing legislation in a variety of states. [More]

Putting State Innovation Model (SIM) dollars to work

The SIM initiative seeks to advance and accelerate state delivery system and payment reform efforts. Under Section 3021 of the Affordable Care Act (ACA), SIM grants may be awarded to states and territories that demonstrate a comprehensive plan that transforms the delivery system, aligning with the “triple aim” objectives of reducing costs, improving quality, and population health.
To date the Centers for Medicare and Medicaid Innovation (CMMI) has issued a total of 38 SIM awards to 34 states, three territories, and the District of Columbia, for model design and testing. The initiatives underway in SIM grant models touch 61% of the population.
These awards are broken into: [More]

21st Century Cures Act

On December 7, 2016 Congress passed the 21st Century Cures Act (the “Act”), which was signed into law on December 14, 2016. The Act is aimed at modernizing health care delivery, improving quality and targeted improvements in the area of cancer treatment, mental health care, opioid addiction, and other focused areas. One such modernization effort requires states to implement Electronic Visit Verification (EVV) systems for personal care services and home health care services providers by 2019 and 2023, respectively. These EVV systems will help ensure that beneficiaries receive the care that is being billed to Medicaid. Additionally, the Act allocates over $1 billion in grant funding over the next two years for states to combat the opioid epidemic. States began the application process for grant funds in early 2017, and efforts are now underway in a number of states to implement new programs and services focused on treatment and prevention. Below we highlight one way PCG has identified to leverage existing claims data to implement reforms. This Act is largely funded through the Prevention and Public Health fund established in the Affordable Care Act (ACA). For more information on additional modernization and reform elements of the Act, please click here. [More]

CMS releases final Market Stabilization Rule

On April 13, 2017, the Centers for Medicare and Medicaid Services (CMS) released the final Patient Protection and Affordable Care Act; Market Stabilization Rule. The final rule is aimed at stabilizing the individual and small group markets by tightening enrollment standards and providing increased flexibility related to standards for Qualified Health Plans (QHPs), as outlined in detail below. The final rule also seeks to provide greater deference to state regulation of health insurance. [More]

Update on House v Burwell case

On December 5, 2016, the District of Columbia Circuit Court of Appeals accepted a Congressional request to postpone further proceedings in House v Burwell pending motions due February 21, 2017, turning the continued proceedings in this case over to the next administration and Congress.

In November 2014, the House of Representatives filed suit against the current administration claiming the cost-sharing reduction payments made to issuers for silver level Marketplace enrollees, with incomes of less than 250% of the Federal poverty level, are not lawful because Congress has not appropriated the funds. [More]

Insights from the annual National Academy of State Health Policy Conference - #NASHPCONF16

From October 17th to 19th, members of PCG’s Health Policy team attended the annual National Academy of State Health Policy (NASHP) Conference in Pittsburg, PA. The theme for this year’s event was “Where Ideas and Action Converge,” with particular focus on Delivery System Reform Incentive Payment (DSRIP) waivers, Medicaid expansion and payment and delivery system reform innovation. In addition to presentations highlighting the innovative efforts in states under waiver and grant programs, discussions led by state and national policy makers on health care’s more headline grabbing topics (e.g., opiate abuse, ever-growing prescription drug costs, etc.). were weaved through the three-day agenda. [More]

Consumer assistance for open enrollment 2017

This year, for the first time since the health insurance marketplace began, states will not have the support of consumer assistance funding from the Centers for Medicare and Medicaid Services (CMS) to educate the public about marketplace plan offerings. Without federal funding, many states are scrambling to find ways to assist consumers in the upcoming open enrollment period. [More]

Alabama’s Regional Care Organization 1115 waiver approval

In May 2013, Act-2013-261, Ala. Code §§ 22-6-150 was passed, advancing the move from a fee-for-service (FFS) system to a managed care program. According to the Alabama Medicaid Advisory Board report issued in January 2013, based on 2011 data, 22 percent of Alabama’s population was Medicaid eligible for a portion of the year. Additionally, Alabama’s Medicaid program covered 53 percent of births, 47 percent of children, and two-thirds of nursing home residents. In 2009, Medicaid accounted for 16.3 percent of all health care expenditures in Alabama. In order to contain costs associated with the substantial Medicaid population, managed care in the form of regional care organizations (“RCOs”) were established with little guidance other than the Act 2013-261 itself. [More]

CMS announces the release of $22 Million in Health Insurance Enforcement and Consumer Protections grant funding

On June 15, 2016, the Centers for Medicare and Medicaid (CMS) announced the release of $22 million in grant funding for State planning and implementing of the health insurance market reform provisions of the Affordable Care Act (ACA). The grants are aimed at helping States ensure their laws, regulations and procedures are in line with Federal requirements and that the States are able to effectively monitor and enforce health insurance market reforms and consumer protections under the ACA. States must submit a letter of intent by July 6th. Grant applications are due August 15th at 3:00 pm. [More]