Cooperating for better care.


Tag Archives

CMS seeks to give states more freedom to define essential benefits


FierceHealthcare reports that the  Trump administration has proposed a new federal rule to  give states more freedom  to define essential health benefits, as well as other changes to the regulations governing the individual and small-group markets.

The 2019 Notice of Benefit and Payment Parameters (PDF) was released Friday by the Centers for Medicare & Medicaid Services.

Fierce reported that “{p}erhaps most notably, CMS’s proposed rule would allow states to alter their essential health benefits  {EHB} benchmark plan annually, beginning as early as 2019.”

“As mandated by the Affordable Care Act, insurers in the individual and small-group markets will still have to cover 10 basic benefits, such as preventive care and prescription drugs. But once CMS’s proposed rule takes effect, states could borrow another state’s EHB benchmark plan—in whole or part—or create a new one altogether, provided it follows certain criteria,” the news service reported.

CMS said: “In addition to granting states more flexibility regulating their markets, we believe this change would permit states to modify EHBs to increase affordability of health insurance in the individual and small group markets.”

But the agency conceded that the proposed changes might cause some people  with specific health needs to lose coverage for certain services, depending on what option their state chooses.

 Fierce reported that CMS also seeks to (in the news service’s words), among other things:
  • “Allow states to assume a larger role in the qualified health plan certification process for the federally facilitated exchanges.”
  • “Explore ways to make state-based exchanges that use the platform a more appealing and sustainable option for states.”
  • “Gives states ‘significantly more flexibility’  {in CMS’s words} in how they operate a Small Business Health Options Program, also known as SHOP.”
  • “Recalibrate the parameters for risk adjustment methodology and give states more flexibility regarding risk adjustment transfers in their markets.”
  • “Let states  apply for an adjustment to their individual market medical loss ratio standard.”
  • “Raise the threshold for review of ‘unreasonable’ premium increases from 10% to 15%.”
  • “Remove the requirement that each exchange have at least two navigator entities, and the rule that navigators provide in-person outreach/enrollment support.”

To read more, please hit this link.


Trump can still shrink Medicaid


For Kaiser Health News

After the Senate fell short in its effort to repeal the Affordable Care Act, the Trump administration is poised to use its regulatory powers to accomplish what lawmakers could not: shrink Medicaid.

President Trump’s top health officials could engineer lower enrollment in the state-federal health insurance program by approving applications from several GOP-controlled states eager to control fast-rising Medicaid budgets.

Indiana, Arkansas, Kentucky, Arizona and Wisconsin are seeking the administration’s permission to require adult enrollees to work, submit to drug testing and demand that some of their poorest recipients pay monthly premiums or get barred from the program.

Maine plans to apply Tuesday. Other states would likely follow if the first ones get the go-ahead.

Josh Archambault, senior fellow for the conservative Foundation for Government Accountability, said absent congressional action on the health bill “the administration may be even more proactive in engaging with states on waivers outside of those that are already planning to do so.”

The hope, he added, is that fewer individuals will be on the program as states figure out ways “to transition able-bodied enrollees into new jobs, or higher-paying jobs.” States need to shore up the program to be able to keep meeting demands for the “truly needy,” such as children and the disabled, he added.

To Medicaid’s staunchest supporters and most vocal critics alike, the waiver requests are a way to rein in the $500 billion program that has undergone unprecedented growth the past four years and now covers 75 million people.

Waivers have often been granted in the past to broaden coverage and test new ways to deliver Medicaid care, such as through private managed-care organizations.

But critics of the new requests, which could be approved within weeks, said they could hurt those who are most in need.

The National Health Law Program “is assessing the legality of work requirements and drug testing and all avenues for challenging them, including litigation,” said Jane Perkins, the group’s legal director.

The administration has already said it favors work requirements and in March invited states to suggest new ideas.

Before taking the top job at the Centers for Medicare & Medicaid Services, Seema Verma was the architect of a Kentucky waiver request submitted last year.

Not all states are expected to seek waivers, because Medicaid enjoys wide political support in many states, particularly in the Northeast and West.

Medicaid, the nation’s largest health insurance program, has seen enrollment soar by 17 million since 2014, when Obamacare gave states more federal funding to expand coverage for adults. It’s typically states’ second-largest expense after education.

This year, Senate and House bills tried to cap federal funding to states for the first time. Since the program began in 1965, federal Medicaid funding to states has been open-ended.

Health experts say allowing the waiver requests goes beyond the executive branch’s authority to change the program without approval from Congress.

“The point of these waivers is not for states to remake the program whole-cloth on a large-scale basis,” said Sara Rosenbaum, a health-policy expert at George Washington University who chairs a Medicaid group that advises Congress.

Rosenbaum noted that states received waivers for different purposes under the Obama administration.

In Iowa, state officials won the authority to limit non-emergency transportation. Indiana received approval to charge premiums and lock out enrollees with incomes above the federal poverty level if they fell behind on paying premiums.

“Now there is concern these more extreme measures would hurt enrollees’ access to care,” Rosenbaum said.

Three states seeking waivers today are home to three key GOP players in the Senate health debate: Majority Leader Mitch McConnell (Kentucky), Sen. John McCain (Arizona) and Vice President Mike Pence (Indiana).

If states add premiums, as well as work and drug testing requirements, the result would be fewer people enrolling and staying in Medicaid, said David Machledt, senior policy analyst for the National Health Law Program.

“How does that serve the purpose of the Medicaid program and what are the limits of CMS waiver authority?” he asked.

Physicians group urges review of pain-management standards


A group of physicians urge the Joint Commission and the CMS to end policies that the group says can lead to opioid overprescribing and addiction.  The action came as the nation tries to deal with the opioid epidemic.
Signatories asked the Joint Commission to re-examine its Pain Management Standards — which once helped push the idea of pain as the “fifth vital sign” — and asked the  CMS to get rid of patient-satisfaction questions about pain from its reimbursement procedures.

The letters were sent by Physicians for Responsible Opioid Prescribing (PROP), other medical and consumer groups and by senior health officials from Pennsylvania, Vermont, Alaska and Rhode Island.


This patient-centered counseling didn’t do much


This piece in JAMA Internal Medicine looks at the efficacy of promoting patient-centered counseling to reduce use of low-value diagnostic tests.

The mission was  “to evaluate the effectiveness of a standardized patient (SP)-based intervention designed to enhance primary care physician (PCP) patient-centeredness and skill in handling patient requests for low-value diagnostic tests.”

The authors concluded that “An SP-based intervention did not improve the patient-centeredness of SP encounters, use of targeted interactional techniques, or rates of low-value test ordering, although SPs were more satisfied with intervention than control residents.”

Small-group insurance market expansion in play

The National Journal reports that Republicans might get a chance this fall  to overturn the Affordable Care Act’s expansion of the small-group insurance market — and  that President Obama might go along with the change.

A deadline looms:  The ACA mandate that states  widen the definition of their small-group markets from employers with 50 or fewer employees to 100 or fewer is supposed to start to take effect in some states on Jan. 1. But legislation, The National Journal says, “would end that requirement,  leaving the definition at the historical norm of 50 while letting states set it higher….”

Timothy Jost, a healthcare expert at Washington and Lee University, noted  to the magazine some potential problems if the change  were made. The magazine paraphrased him as saying that “While prices might go down for the 50-and-under businesses as their market grew, the 51-to-100 businesses would almost certainly see their prices go up. They would be moving from the more stable and typically less expensive large-group plans to the small-group setting. The small-group market is also subject to some Obamacare rules, such as covering certain essential health benefits, that the large-group market is not. Some estimates have projected that costs would actually increase for everybody.”

Still, “{o]f all the {ACA} ‘fix’ bills floating around the Capitol, the small-group provision might have the most working in its favor: It has bipartisan support, costs little to nothing to change, and even some Obamacare supporters say the law could function fine with the alteration,” the magazine reported.

Conn. hospitals plead for end of provider tax


Connecticut’s hospitals assert that phasing out  the state provider tax is  needed to protect healthcare services and jobs.

The Connecticut Hospital Association proposes that state phase out the levy over the next five years, asserting that it costs the Nutmeg State’s hospitals more than $250 million every year.

Contact Info

(617) 230-4965

Wellesley, Mass