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February 2015 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: Department of Insurance Consumer Services ACA Toolkit
State Health Reform Assistance Network
In order to ensure that Consumer Services Divisions within state insurance regulatory agencies are equipped with the necessary resources to assist consumers experiencing insurance problems, the State Health Reform Assistance Network has developed a toolkit intended as a guide for consumer service representatives (CSRs). The resources in this updated toolkit include a reference manual with multiple entries across a number of categories, a glossary of acronyms, terms, and definitions, a benefits crosswalk template, and a reference table illustrating the applicability of ACA provisions to grandfathered and self-funded plans. 

Insurance Exchanges

Final HHS Notice of Benefit and Payment Parameters for 2016
U.S. Department of Health and Human Services
This final rule sets forth 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 finalizes additional standards for the individual market annual open enrollment period for the 2016 benefit year, 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.

The Cost of Care with Marketplace Coverage
Kaiser Family Foundation
Private insurance plans typically require some form of cost sharing (also called out-of-pocket costs) when enrollees receive a health care service covered by their plan.  These expenses, which are in addition to the amount an enrollee spends on his or her monthly premium, come in a variety of forms, including copayments, coinsurance, and deductibles. Insurers use cost sharing to keep down monthly premiums, but cost sharing can also lead to unexpected costs for some enrollees and can be difficult to decipher when shopping for plans or reviewing medical bills. This brief shows the cost sharing in plans sold to individuals through, with a focus on the variation in the ways plans may set cost sharing for services, such as physician visits, prescription drugs, and hospital stays.

Insurance Brokers and the ACA: Early Barriers and Options for Expanding Their Role
Urban Institute and Robert Wood Johnson Foundation
The Affordable Care Act's drafters envisioned a continuing, significant role for brokers in the reformed nongroup insurance market, but circumstances limited their active participation in the first year of marketplace enrollment. This analysis delineates the early barriers to brokers' full engagement, highlights the main concerns with them having a more prominent role, and offers options for making them more effective in enrolling the uninsured. The information presented in this brief is based on interviews conducted with stakeholders (e.g., providers, insurers, consumer advocates, navigators, assisters, brokers) in 21 states and the District of Columbia during the first half of 2014.


The ACA and Medicaid Expansion Waivers
Kaiser Family Foundation
This brief provides an overview of the role of Section 1115 waivers in expanding Medicaid coverage since the enactment of the ACA.  The brief also highlights key themes in those waivers including implementing the Medicaid expansion through a premium assistance model, charging premiums, eliminating certain required benefits (most notably non-emergency medical transportation), and using healthy behavior incentives. Provisions that CMS has not approved are also identified in the brief.

An Overview of New CMS Data on the Number of Adults Enrolled in the ACA Medicaid Expansion
Kaiser Family Foundation
New preliminary data from the Medicaid Budget and Expenditure System (MBES) released by the Centers for Medicare and Medicaid Services (CMS) details for the first time the number of adults enrolled in Medicaid under the new Affordable Care Act (ACA) Medicaid expansion category. The data show that, as of March 2014, among 48 states reporting data, 4.8 million adults out of the total 54.1 million individuals enrolled in Medicaid were in the ACA Medicaid expansion category. These data provide another element of Medicaid enrollment that differs from other enrollment data released from CMS as part of its Medicaid and CHIP Performance Indicator Project, which provide point-in-time Medicaid and CHIP enrollment data to support program management and oversight. These two data sets are not comparable; they have different purposes and include different populations. This issue brief provides an overview of the new data as well as how it differs from the Performance Indicator data.

Strategic Planning

Characteristics of Those Eligible for Cost-Sharing Reductions and Premium Tax Credits Under the Affordable Care Act
Urban Institute and Robert Wood Johnson Foundation
The Affordable Care Act provides financial assistance via cost sharing reductions (CSR) and premium tax credits to help modest-income individuals purchase health insurance and reduce the direct costs of their care. This brief estimates the characteristics of the CSR-eligible population using the Urban Institute’s Health Insurance Policy Simulation Model. Researchers found that the CSR eligible individuals are most likely to live in the South, to be single adults without children, and to be White, non-Hispanics. Researchers also estimate the average value of a CSR to be $479 in 2016, with the value varying by the eligible person’s income.

Adults who Remained Uninsured at the End of 2014
Kaiser Family Foundation
In January 2014, the major coverage provisions of the Affordable Care Act (ACA)—including the expansion of Medicaid eligibility and the availability of subsidized coverage through Health Insurance Marketplaces— went into effect. As the first year of new coverage under the ACA comes to a close and the end of the second open enrollment period nears, there is great interest in understanding why some people continue to lack coverage and in reaching out to the eligible uninsured. This report, based on the 2014 Kaiser Survey of Low-Income Americans and the ACA, profiles the nonelderly adult population that remained uninsured as of Fall 2014.

Delivery System Redesign

Supporting Social Service Delivery through Medicaid Accountable Care Organizations: Early State Efforts
Center for Health Care Strategies, Inc.
Given the often overwhelming prevalence of social needs facing Medicaid populations, including housing, transportation, and nutrition, aligning social services and supports with health care delivery is critical. Many states recognize the connection between social determinants of health and health care utilization and outcomes, and are building the infrastructure to support social service delivery through accountable care organization (ACO) programs. This brief highlights the initial efforts of seven states — Colorado, Maine, Minnesota, New York, Oregon, Vermont, and Washington — that participated in CHCS’ Medicaid ACO Learning Collaborative, and outlines key themes and considerations from these early adopters to help additional states support collaboration between ACO and social service providers.