Manatt on Health Reform: Weekly Highlights

A federal report finds that Marketplace premiums are lower in expansion states; Massachusetts and Pennsylvania launch prescription drug monitoring systems; and Kentucky submits a slightly modified Medicaid expansion waiver to CMS.


CMS Proposed Rule Would Modify Risk Adjustment Program and Enhance Marketplace Consumer Experience

Released August 29, CMS’s sweeping proposed 2018 Notice of Benefit and Payment Parameters includes several amendments to the risk adjustment program aimed at strengthening the risk pool and supporting issuers entering the Marketplace or expanding their Marketplace business. The proposed changes arrive on the heels of growing concern about Marketplace stability and premium increases, spurred by several issuers announcing planned Marketplace exits. If adopted as proposed, the new rule would: modify risk adjustments to account for enrollees who do not stay with an issuer for a full plan year; leverage prescription drug utilization data to more accurately reflect the severity of enrollees’ health conditions; and spread the financial burden across issuers when an enrollee’s healthcare costs exceed $2 million. CMS also is requesting feedback on how special enrollment period (SEP) policies can be modified to strengthen Marketplace risk pools. Other measures are aimed at enhancing the consumer experience, including additional tools that allow consumers to compare provider networks across plans and new consumer protections for those who enroll through brokers or directly with an issuer.

Premium Tax Credits and Ability to Switch Plans Protect Marketplace Customers From Significant Premium Increases

The combination of premium tax credits and the opportunity to shop for coverage helps ensure that Marketplace customers have access to affordable health coverage, even if premium increases are significant, according to a brief from HHS’s Office of the Assistant Secretary for Planning and Evaluation. If all issuers increased their qualified health plan premiums by 25% for 2017 (a “highly unrealistic” assumption, according to the brief), 78% of customers could find coverage for $100 or less per month. If there were a 50% premium increase, 80% could purchase coverage for $100 or less. Since tax credits are calculated based on the cost of the second-lowest-cost silver plan (the “benchmark” plan), a higher across-the-board premium generates higher subsidies, allowing people eligible for tax credits to spend less out of their own pocket if they are willing to buy one of the plans that is priced below the benchmark plan. The average Marketplace premium increased 8% between 2015 and 2016.

One-Fifth of 2017 Marketplace Enrollees May Have One Insurer Option, Preliminary Data Suggests

An estimated 19% of enrollees are likely to have only one Marketplace insurer to choose from in 2017, compared to 2% in 2016, according to a preliminary analysis from the Kaiser Family Foundation commissioned by The Wall Street Journal. An estimated 62% of 2017 enrollees will have a choice of three or more insurers, which is down from 85% in 2016. Kaiser caveats its findings, noting that “it is too soon to say with certainty” how many Marketplace insurers there will be in 2017.

Arkansas: Marketplace Committee Endorses First Step in Transition to the Federal Platform

The Marketplace Board's Consumer Assistance Committee endorsed a $552,000 proposal to hire approximately 15 full-time navigators, a first step in the State’s proposed transition from a State Partnership Marketplace to a State-based Marketplace on the Federal Platform (SBM-FP). As an SBM-FP, Arkansas would take over responsibility for certifying, managing, and conducting outreach for individual Marketplace plans, while continuing to rely on's eligibility and enrollment system. The State plans to charge Marketplace carriers a 3% fee on plan premiums to fund the navigator program and other Marketplace operations. The fee on carriers will also fund the federal fee (1.5% of plan premiums) charged to SBM-FP states for use of the eligibility and enrollment platform. The full Marketplace Board will vote on the navigator proposal on September 21.

Wisconsin: Insurance Commissioner Opposes CMS’s Automatic Re-Enrollment Policy

Ted Nickel, the State’s Commissioner of Insurance, intends to prevent insurers from participating in CMS’s auto re-enrollment policy, citing violation of State law and lack of authority in the ACA, according to a letter Nickel sent to CMS’s Marketplace CEO Director Kevin Counihan. The Commissioner’s dispute centers around new processes that CMS promulgated whereby enrollees whose coverage ends due to an insurer’s exit from the Marketplace could be automatically assigned to a different issuer’s plan. According to Nickel, CMS explained in a letter to the State that enrollees will still be required to take an affirmative action (paying the first month’s premium) to enter into the contract with the new issuer. Nickel intends to issue a bulletin that would make any insurer who accepts enrollees through CMS’s auto reassignment policy subject to sanctions; the State would also seek restitution for any resulting harm consumers may experience.


Kentucky: State Submits 1115 Waiver to CMS to Reform Medicaid Expansion Program With Minimal Changes

Governor Matt Bevin (R) submitted an 1115 waiver application to CMS following a 30-day public comment period that produced nearly 1,500 comments. The waiver application reflected minimal changes from the draft application, including: specifying that premiums would be charged per household rather than per individual, clarifying excluded populations, and removing a proposal to eliminate allergy testing from the benefit package. As reported in June, “Kentucky HEALTH” would implement two new coverage vehicles for the expansion population: a high-deductible Medicaid managed care plan accompanied by an account for plan deductibles, and an employer-sponsored insurance premium assistance program. Members would receive a “My Rewards Account” for enhanced benefits such as vision or dental, but would be subject to monthly premiums, a work/community engagement requirement, and a lock-out period if they do not complete renewal forms in a timely way. To date, no state has secured CMS approval for a work requirement or a lock-out period for failure to comply with renewal requirements. The federal agency recently denied Indiana's request for such a lock-out period.

Massachusetts: Behavioral Health Screenings Jump 70 Percentage Points Among Medicaid-Enrolled Children and Adolescents

A Journal of Pediatrics study found that nearly 75% of children and adolescents enrolled in MassHealth (the State’s Medicaid program) received behavioral health screenings in 2012, up from 4% in 2007, the last year before primary care providers were mandated to offer formal behavioral health screenings to all MassHealth enrollees under age 21. The screenings are conducted as part of the Children’s Behavioral Health Initiative (CBHI), an interagency initiative created in response to a 2001 legal settlement that aims to ensure children with significant behavioral, emotional, and mental health needs can access the services they need. CBHI requires standardized screening and assessments for children at well child and mental health visits and promotes enhanced home- and community-based behavioral health services.


Medicaid Expansion Associated With Lower Marketplace Premiums, Study Finds

Marketplace premiums in Medicaid expansion states are approximately 7% lower than Marketplace premiums in non-expansion states, according to HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE). The authors note that a key difference in Marketplace enrollment between expansion and non-expansion states is whether individuals with incomes between 100% and 138% of FPL are enrolled in the Marketplace (as is the case for non-expansion states) or in Medicaid (as is the case for expansion states). ASPE links the higher premiums in non-expansion states—where 40% of enrollees have incomes between 100% and 138% of FPL—to less healthy Marketplace risk pools, citing the “substantial body of scientific literature” that connects having a low income to greater risk of poor health. The analysis compared neighboring counties in different states and controlled for differences in demographics, pre-ACA uninsured rates, healthcare costs, and state policy decisions other than Medicaid expansion.

CMS Publishes Web-Based Form for Issuers’ Contraceptive Claim Costs on Behalf of Organizations With Religious-Based Objections

CMS released details on the financing mechanism that accommodates organizations that object to paying for contraceptive coverage for religious reasons. issuers (or third-party administrators and pharmacy benefit managers who partner with issuers) can use a new web-based form to report contraceptive payments made on behalf of enrollees in self-insured group health plans sponsored by organizations that choose not to provide contraceptive services due to religious-based objections. CMS will use the information submitted through the form to adjust issuers' FFM user fees to fund the contraceptive payments. Issuers have until September 20 to report contraceptive claims paid for during 2015.

To Address Rising Prescription Drug Costs, NAIC Report Recommends Capped Cost-Sharing and Standardized Formularies

Consumer representatives to the National Association of Insurance Commissioners (NAIC) released a wide-ranging analysis of prescription drug coverage policies and offered a multitude of recommendations for promoting access to affordable prescription drugs. The report, which is aimed at state policymakers, consumer advocates and healthcare stakeholders, addresses cost-sharing, formulary transparency, and value-based pricing for emerging therapies, among nearly a dozen other policy areas. It recommends prohibiting plans from placing most or all drugs for the same condition in any specialty tier, capping cost-sharing and copays and eliminating or reducing cost-sharing for “high-value medications” (i.e., those that are most likely to be effective for an individual based on his/her specific clinical needs). The report also suggests that plans be required to provide consumers with standardized, comprehensive, and electronically accessible formularies prior to enrollment to promote formulary transparency. To facilitate value-based pricing, which is cited as particularly important in the emerging drugs market since it can reduce costs where traditional competition may not, the report recommends that pharmacy and therapeutics committees review newly approved therapies or indications within 90 days of FDA approval and make a coverage determination within 180 days of release onto the market.

Massachusetts: Prescription Monitoring Program Launched

With an eye on the opioid epidemic, a newly-launched online prescription monitoring system called "MassPAT" allows providers in Massachusetts to view all prescriptions filled for federally-controlled substances for State residents by pharmacies in Massachusetts, Connecticut, Rhode Island and Vermont. New York will be added this month and Maine and New Hampshire are expected to be added in the future. Launch of the improved online system—with a more user-friendly and rapid-response interface, improved compatibility with electronic medical records systems, and onboarding improvements for users—fulfills a recommendation of Governor Charlie Baker's (R) Opioid Working Group, which released its findings last summer.

Minnesota: Hospital Charity Care Costs Down Since 2013

The State’s ten largest hospital systems experienced a 15% decline in charity care costs since 2013, according to a Star Tribune analysis. The decline in charity care costs, which had been increasing between 2011 and 2013, corresponds with a drop in the State's uninsurance rate to below 5% since the ACA Marketplace was established and Medicaid was expanded in 2014. The analysis found that bad debt (uncompensated care for patients ineligible for free care) also decreased between 2014 and 2015, though not below 2013 levels, which the authors link to the growing number of patients struggling to pay high deductibles.

Pennsylvania: Prescription Drug Monitoring Database Launches to Combat Opioid Epidemic

Pennsylvania launched a Prescription Drug Monitoring Program intended to help clinicians monitor the type and frequency of prescriptions patients receive as part of an effort to reduce opioid deaths in the State. Pharmacies and physicians will input prescribing and dispensing information into the database to track the number of opioid prescriptions a patient fills and physicians will be required to search for a patient in the database when prescribing a potentially addictive drug for the first time. Governor Tom Wolf (D) announced the program as part of the State's ongoing effort to cut down on the 3,500 Pennsylvanians who die each year from drug overdose.


New Hampshire: State Appoints New Medicaid Director

New Hampshire's Commissioner of Health and Human Services (DHHS) appointed Deborah Fournier the State's Medicaid Director, as announced through an email to DHHS staff members. Fournier served as Interim Director for the previous two months in place of Katie Dunn, who left the position to become a Senior Program Director at the National Academy for State Health Policy.



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