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November/December 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

2016 Benefit and Payment Parameters Proposed Rule

U.S. Department of Health and Human Services

This proposed rule provides payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also provides additional standards for the annual open enrollment period for the individual market for benefit years beginning on or after January 1, 2016, essential health benefits, qualified health plans, network adequacy, quality improvement strategies, the Small Business Health Options Program, guaranteed availability, guaranteed renewability, minimum essential coverage, the rate review program, the medical loss ratio program, and other related topics. Comments on the proposed rule are due by December 22, 2014.

Insurance Exchanges

Marketplace Renewals: State Efforts to Maximize Enrollment into Affordable Health Plan Options

Georgetown University Health Policy Institute

To achieve enrollment targets for 2015, the health insurance marketplaces must rely on millions of consumers renewing their current marketplace health plans. This is no small effort, and the marketplaces are constrained by information technology capacity, a short enrollment time frame, and limited resources for outreach and consumer assistance. This report examines the efforts of six state-based marketplaces (California, Colorado, Kentucky, Maryland, Rhode Island and Washington) to successfully renew health coverage for millions of marketplace enrollees.

Affordability of Marketplace Coverage: Challenges to Enrollment and State Options to Lower Consumer Costs

Urban Institute and the Robert Wood Johnson Foundation

The end of the ACA’s first open enrollment period has seen better-than-expected participation and a significant drop in the number of uninsured, particularly in states that expanded Medicaid. However, many eligible uninsured have not yet signed up. This paper focuses on one factor that has emerged as a challenge to marketplace enrollment: namely, consumers’ perception that, even with federal subsidies, Qualified Health Plans are not affordable. The paper begins by analyzing how this factor played out during the open enrollment season for 2014, and then describes promising practices implemented by particular states to improve the affordability of coverage.

Establishment of the Multi-State Plan Program for the Affordable Insurance Exchanges

Office of Personnel Management

The U.S. Office of Personnel Management (OPM) issued a proposed rule to implement modifications to the Multi-State Plan (MSP) Program based on the experience of the program to date. This proposed rule clarifies the approach used to enforce the applicable requirements of the Affordable Care Act with respect to health insurance issuers that contract with OPM to offer MSP options. This proposed rule amends MSP standards related to coverage area, benefits, and certain contracting provisions under section 1334 of the Affordable Care Act. This document also makes non-substantive technical changes.

Public Education, Outreach and Application Assistance

Urban Institute and the Robert Wood Johnson Foundation

This report analyzes the public education and application assistance strategies employed during the 2014 open enrollment period based primarily the Health Reform Monitoring Survey (HRMS) and interviews with diverse informants in 24 states.  In addition to describing general trends involving public education and application assistance, this analysis shares promising practices used by particular states as well as suggestions offered by stakeholders and researchers. Such practices and suggestions focus primarily on state-based and partnership marketplaces, but many could also apply to federally-facilitated marketplaces.


Minimum Essential Coverage Guidance

Centers for Medicare and Medicaid Services

This letter provides guidance on the types of Medicaid coverage that qualify as minimum essential coverage (MEC), which includes certain coverage for low-income pregnant women, coverage for medically needy individuals, and coverage under an 1115 waiver program. This letter also clarifies how other Medicaid and CHIP coverage is regarded as MEC, and discusses related federal guidance issued by the Internal Revenue Service (IRS) to ensure pregnant women are not adversely impacted by a decision either to recognize or to not recognize certain coverage as MEC. Finally, this letter discusses hardship exemptions and the availability of special enrollment periods for individuals enrolled in Medicaid coverage that is not MEC.

The ACA’s Basic Health Program Option: Federal Requirements and State Trade-Offs

Kaiser Family Foundation

The ACA gives states the option to implement a Basic Health Program (BHP) that covers low-income residents through state-contracting plans outside the health insurance marketplace, rather than qualified health plans (QHPs). BHP offers the prospect of improved affordability for low-income residents, fiscal gains for some states, and reduced churning. However, it also poses financial risks for states and has implications for state marketplaces. This paper summarizes the federal policies on BHP, including the requirements for BHP as well as the methodology for determining federal BHP payments. It also analyzes the key trade-offs facing states as they decide whether and, if so, how to implement BHP, with a particular focus on the impact of BHP on state budgets and the size, stability, and risk level of state marketplaces.

Strategic Planning

Public Health’s Role in a Post-ACA World


The ACA contains several provisions that may alter the scope and practice of public health. As a result, governmental health departments must evolve in order to accommodate the new health landscape and changing demands on the system. In the wake of these health systems changes, public health faces new opportunities and challenges. This recently-released Research Insights brief examines the role of public health following ACA implementation by looking at three innovative approaches to governmental public health – in Massachusetts, San Diego, and Vermont.

Too High a Price: Out-of-Pocket Health Care Costs in the United States

The Commonwealth Fund

Whether they have health insurance through an employer or buy it on their own, Americans are paying more out-of-pocket for health care now than they did in the past decade. A Commonwealth Fund survey fielded in the fall of 2014 asked consumers about these costs. More than one in five 19-to-64-year old adults who were insured all year spent 5 percent or more of their income on out-of-pocket costs, not including premiums, and 13 percent spent 10 percent or more. Adults with low incomes had the highest rates of steep out-of-pocket costs. Two of five adults with private insurance who had high deductibles relative to their income said they had delayed needed care because of the deductible.

Delivery System Redesign

Promoting Physical and Behavioral Health Integration: Considerations for Aligning Federal and State Policy
National Academy for State Health Policy

Federal and state policymakers are faced with the challenge of integrating services to address both the physical and behavioral health needs of the population. This brief summarizes key lessons and opportunities for federal and state alignment that surfaced during a meeting supported by The Commonwealth Fund of high-level federal and state leaders. Several case studies are featured including Arizona, Missouri and Tennessee. Opportunities discussed spanned payment models, information and data sharing approaches, as well as operational strategies for achieving integration.

An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers

Kaiser Family Foundation

Delivery System Reform Incentive Payment (DSRIP) initiatives are part of broader Section 1115 Waiver programs and provide states with significant funding that can be used to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries.  While they originally were more narrowly focused on funding for safety net hospitals and often grew out of negotiations between states and HHS over the appropriate way to finance hospital care, they increasingly are being used to promote a far more sweeping set of payment and delivery system reforms. This brief examines similarities and difference across key elements of DSRIP waivers in six states – California, Texas, Kansas, New Jersey, Massachusetts, and New York.