Reports & Analysis

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Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016

Jan 2016

This 14th annual 50-state survey of Medicaid and CHIP eligibility, enrollment, renewal, and cost-sharing policies provides a point-in-time snapshot of policies as of January 2016 and identifies changes in policies that occurred during 2015. Coverage is driven by two key elements—eligibility levels determine who may qualify for coverage, and enrollment and renewal processes influence the extent to which eligible individuals are enrolled and remain enrolled over time. This report provides a detailed overview of current state policies in these areas, which have undergone significant change as a result of the ACA.


Insurer Participation in State-Based Marketplaces in 2016: A Closer Look

Jan 2016

At the outset of the third open-enrollment period for the Affordable Care Act’s (ACA) health insurance marketplaces, the U.S. Department of Health and Human Services (HHS) reported that the number of insurance companies participating in the federally run marketplaces would remain relatively consistent from 2015 to 2016. This analysis of the 17 state-based marketplaces also found stable participation. Despite the struggles of many Consumer Operated and Oriented Plans (CO-OPs) and persistent market challenges, most state-based marketplaces have an equal or greater number of insurers competing for business this year.


Why Are Many CO-OPs Failing? How New Nonprofit Health Plans Have Responded to Market Competition

Jan 2016

The Affordable Care Act (ACA) created the Consumer Operated and Oriented Plan (CO-OP) Program to provide consumer-focused health insurance options. But the CO-OP experience to date reveals factors that limit market competition. This report considers the challenges that CO-OPs have faced through analysis of plan, pricing, and enrollment data for six CO-OPs. It describes how CO-OPs responded to the prohibition on using federal loans for marketing, problems associated with outsourcing health plan functions, CO-OP plan design and pricing strategies, dynamics of both high and low enrollment, and challenges related to the ACA’s premium stabilization programs. It includes a discussion of the role of federal and state policy decisions in adding to rather than reducing barriers to market entry for CO-OPs.


Bundled Payments for Care Improvement Initiative

Dec 2015

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 brief describes the different models being tested and CMS’s experience with the project to date.


Opportunities to Improve Models of Care for People with Complex Needs

Dec 2015

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.


Enforcing Mental Health Parity

Dec 2015

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.


Making Affordable Care Act Coverage a Reality: A National Examination of Provider Network Monitoring Practices

Dec 2015

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.


Toolkit: State Strategies to Enroll Justice-Involved Individuals in Health Coverage

Dec 2015


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.


Insurance Marketplace Enrollment Reports

Dec 2015

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.


Patient Cost-Sharing in Marketplace Plans, 2016

Dec 2015

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.

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