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November/December 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 Reform

2017 Essential Health Benefits Benchmark List
Centers for Medicare and Medicaid Services
On November 9, 2015, the Centers for Medicare & Medicaid Services released the final 2017 essential health benefits benchmark plan for each state. A summary of benchmark plan coverage and the supporting plan document, as well as a list of how many prescription drugs are covered in each United States Pharmacopeia (USP) category and class were posted. The final list includes feedback received during the 30-day comment period.

State Efforts to Reduce Consumers’ Cost-Sharing for Prescription Drugs
The Commonwealth Fund
As drug prices have been rising, insurers have been shifting the costs to consumers by creating specialty drug tiers that require patients to pay a large percentage of the total cost or very high copays. This new blog post looks at how a number of states have already moved ahead with legislative and regulatory action to help consumers. The authors outline states’ approaches to addressing this issue, including caps on drug spending and, within state marketplaces, standardized insurance benefit designs that limit the number of drug tiers or have fixed copayments.

Insurance Exchanges

Patient Cost-Sharing in Marketplace Plans, 2016
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: copayments, coinsurance, and deductibles. This brief shows the cost sharing in plans sold to individuals through for 2016, 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 Marketplace Enrollment Reports
State Health Access Data Assistance Center (SHADAC)
SHADAC is aggregating State-Based Marketplace (SBM) enrollment reports released during the third ACA Open Enrollment Period (November 1, 2015, to January 31, 2015) and posting them to its marketplace enrollment reports library. The library will also incorporate federal enrollment reports for both Federally Facilitated Marketplaces (FFMs) and SBMs, as well as for Medicaid and the Children’s Health Insurance Program (CHIP). State and federal reports covering the first and second ACA Open and Special Enrollment Periods are also available.


Toolkit: State Strategies to Enroll Justice-Involved Individuals in Health Coverage
National Academy for State Health Policy
Many individuals involved in the criminal justice system are now eligible for Medicaid in states that expanded Medicaid under the ACA. Health coverage can provide individuals who are leaving incarceration with access to physical and behavioral health services critical to their successful reentry into the community. This new toolkit highlights the efforts of select states to enroll individuals involved with the criminal justice system. The toolkit is designed to provide state officials with actionable information about policies and practices available to connect justice-involved individuals to health care coverage through Medicaid.

Strategic Planning

Rural Public Health Systems: Challenges and Opportunities for Improving Population Health
This new research synthesis reviews several published scientific articles and grey literature specific to rural public health systems and local health departments. It finds that rural local health departments struggle to provide essential services; meet accreditation standards; and attract and maintain a strong, competent workforce. This research synthesis spotlights current rural pubic health services and systems research and illuminates current gaps in evidence.

Making Affordable Care Act Coverage a Reality: A National Examination of Provider Network Monitoring Practices by States and Health Plans
Health Management Associates
This study examines the standards and practices that state agencies and health plans use to ensure access to care in the period following the implementation of the Affordable Care Act (ACA). Based on evidence gathered through surveys of and interviews with key informants in state agencies and plans, the study explores the standards applied by commercial insurance regulators and Medicaid agencies and the practices actually employed by Medicaid managed care organizations (MMCOs) and Qualified Health Plans (QHPs) in Marketplaces to form provider networks and monitor performance. The study paints a picture of the range of standards and practices used and the challenges faced, which provides a basis for identifying gaps in current understanding and strategies and opportunities for developing best practices.

Enforcing Mental Health Parity
Health Affairs
This policy brief looks at the issue of enforcing mental health parity five years after the Mental Health Parity and Addiction Equity Act (MHPAEA) took effect. It provides information on the evolution of the Mental Health Parity Act and changes in mental health parity brought about by the implementation of the ACA. The brief also focuses on how MHPAEA is being enforced, a process that has not always been consistent.

Delivery System Redesign

Opportunities to Improve Models of Care for People with Complex Needs
Center for Health Care Strategies
With rapid health care transformation efforts underway across the nation, there is increasing attention on improving outcomes and reducing avoidable health care costs for the small subset of individuals who account for the majority of health care spending. Significant gaps in understanding remain—including how to identify and engage individuals, segment populations into meaningful subgroups with tailored interventions, measure quality outcomes, and align financial incentives across systems. This report aims to identify those opportunities that warrant further exploration, with hopes of targeting future investments and pilot activities to help fill the gaps that remain.

Bundled Payments for Care Improvement Initiative
Health Affairs
The Centers for Medicare and Medicaid Services (CMS) is implementing the Bundled Payments for Care Improvement (BPCI) initiative to test four different alternative payment models based on episodes of care that involve an inpatient hospital stay. One model focuses on care provided during the hospital stay, while the other three models include post-acute care provided once the patient is released from the hospital. CMS hopes that by paying for related care as part of a broad payment bundle, different providers who treat a patient during a single episode will have incentives to better coordinate care, avoid unnecessary services, and improve patient health. This article describes the different models being tested and CMS’s experience with the project to date.