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October 2014 St@teside

Health Reform Resources

SCI keeps its Federal Reform Resources webpage up-to-date with the most recent information from the states, the federal government, and health policy organizations in an effort to guide our readers through the health reform implementation process. We know there are several places to go for the latest health reform resources, and we thank you for using SCI as one of your trusted sources. Here are some of the most recent resources that can be found on our Federal Reform page:

Insurance Market Reforms

Updated Network Adequacy Planning Tool for States

State Health Reform Assistance Network

The Affordable Care Act (ACA) includes certain requirements regarding the adequacy of provider networks developed by health insurers to deliver covered services to their enrollees. The requirements provide broad parameters within which insurance regulators and other state officials responsible for network adequacy must evaluate the networks of Qualified Health Plans operating in their markets. This network adequacy planning tool for states has been updated to reflect the most recent U.S. Department of Health and Human Services regulation on minimum network adequacy standards, and can assist states in developing analysis plans that will inform discussions around updating network adequacy standards.

Implementation of the Affordable Care Act: Six-State Case Study on Network Adequacy

Robert Wood Johnson Foundation and Urban Institute

During the transition to new health plans and new marketplaces under the ACA, many insurers revamped their approach to network design, and many now offer narrower provider networks than they have in the past. In this study for the Robert Wood Johnson Foundation’s project to monitor ACA implementation, researchers assessed network changes and efforts at regulatory oversight in six states: Colorado, Maryland, New York, Oregon, Rhode Island, and Virginia. Researchers found that insurers made significant changes to the provider networks of their individual market plans, both inside and outside the marketplaces, and that insurers took varying approaches to network design.

Insurance Exchanges

The Ninety-Day Grace Period

Health Affairs and Robert Wood Johnson Foundation

To help enrollees new to the system keep their insurance, the ACA provides a ninety-day grace period before an insurer can discontinue their coverage for failure to pay a monthly premium. This grace period applies only to those who have received an advance premium tax credit to purchase health insurance through the Marketplaces and have previously paid at least one month's full premium in that benefit year. This Health Policy Brief focuses on CMS's implementation of the ACA grace period and concerns from hospitals and physicians about potential financial liability now that millions of people have signed up for subsidized health insurance through the Marketplaces.

Taking Stock and Taking Steps: A Report from the Field after the First Year of Marketplace Consumer Assistance under the ACA

Kaiser Family Foundation and Robert Wood Johnson Foundation

This new report captures insights from those who helped consumers navigate the ACA’s first open enrollment period, including lessons for the second, which is set to start Nov. 15. The report draws on the experiences of 80 program leaders who participated in a roundtable discussion convened by the foundations in June. The group talked about consumer education and engagement, options for improving consumer notices and technical support for assisters, ways to better help people make informed choices, and the need to continue assisting consumers after enrollment.


Proposed Notice: Basic Health Program: Federal Funding Methodology for 2016

Centers for Medicare and Medicaid Services

This document provides the methodology and data sources necessary to determine federal payment amounts made in program year 2016 to states that elect to establish a Basic Health Program under the Affordable Care Act in order to offer health benefits coverage to low-income individuals otherwise eligible to purchase coverage through health benefit exchanges.

Increased Service Use Following Medicaid Expansion Is Mostly Temporary: Evidence from California’s Low Income Health Program

UCLA Center for Health Policy Research

One major concern about the Medicaid expansion is that a high level of need among the newly eligible may lead to runaway costs, which could overwhelm state budgets when federal subsidies no longer cover 100 percent of the expansion population's costs starting in 2017. Although cost increases as a result of the newly eligible are likely, an important question is whether these increases will be temporary or permanent. Evidence from California's Low Income Health Program suggests that cost and utilization increases among newly eligible Medicaid beneficiaries will be mostly temporary. The findings presented in this policy brief further suggest that early and significant investments in infrastructure and in improving the process of care delivery can effectively address the pent-up demand for health care services of previously uninsured populations.

Implementing the ACA: Medicaid Spending & Enrollment Growth for FY 2014 and FY 2015

Kaiser Family Foundation

For more than a decade, economic conditions, including two major recessions, were the primary driver of changes in Medicaid spending and enrollment. In FY 2014 and in budgets adopted for FY 2015, enrollment and spending have grown with implementation of the major coverage provisions in the ACA, including the federally financed Medicaid expansion. This report provides an overview of Medicaid spending and enrollment growth with a focus on state fiscal years 2014 and 2015 (FY 2014 and FY 2015) and an overview of Medicaid financing. Findings examine changes in overall enrollment and spending growth and compare expansion and non-expansion states.

Strategic Planning

A Little Knowledge Is a Risky Thing: Wide Gap in What People Think They Know about Health Insurance and What They Actually Know

American Institutes for Research

Under the 2010 Affordable Care Act, millions of Americans gained health coverage in 2014. Coverage is key to accessing affordable, high-quality care, but consumers who struggle to understand how health insurance works and how to estimate out-of-pocket costs are at risk of going without needed care even if they are covered. This brief outlines what health insurance aspects pose the greatest problems for consumers, which groups need more assistance to enroll and use benefits, and what topics and skills consumer-counseling efforts should focus on.

Specialty Medications: Traditional And Novel Tools Can Address Rising Spending On These Costly Drugs

Health Affairs

Spending on specialty medications is growing by more than 15 percent annually, and it is expected to account for approximately half ($235 billion) of total annual pharmacy spending by 2018. Among the numerous reasons for the high cost of this heterogeneous group of medications are the increasing size of target patient populations, the high cost of drug development, and a complex and uncoordinated delivery system. This article describes the evolution of the specialty market, characterizes the current state of specialty medication use, and articulates key challenges and potential solutions. It also explores a variety of traditional and novel management approaches, such as prior authorization, step therapy, tiered formularies, administration at lower-cost sites, and the unique tools being developed for cancer medications.

Delivery System Redesign

Designing Care Management Entities for Youth with Complex Behavioral Health Needs

Agency for Healthcare Research and Quality

Youth with complex behavioral health needs face a range of challenges and often receive services from multiple agencies that do not always coordinate services and care plans. Care Management Entities (CMEs) are designed to coordinate services provided by state agencies, and ensure services are comprehensive and not duplicative. This new Implementation Guide provides information about the CME design process for states interested in implementing or improving CMEs for youth with complex behavioral health needs. The guide focuses on experiences of the three CHIPRA quality demonstration states, Maryland, Georgia, and Wyoming, who are using funds to implement or expand CMEs.

2014 National Scorecard on Payment Reform

Catalyst for Payment Reform

The new National Scorecard on Payment Reform shows commercial health plans have dramatically shifted how they pay physicians and hospitals, with 40 percent of their payments now designed to encourage health care providers to deliver higher-quality and, in some cases, more affordable care. It also shows a 29 percentage point increase over 2013, when just 11 percent of payments were value-oriented. However, 60 percent of payments remain largely traditional fee-for-service. While the Scorecard findings are not wholly representative of all health plans nationally, they offer a baseline against which to measure progress toward value-oriented payment in the commercial sector.