House Democrats Propose Permanent Expansion Of ACA Subsidies

House Democrats propose permanent expansion of ACA subsidies | Modern  Healthcare

Source: Modern Healthcare, by Jessie Hellmann

Biden’s Workplace Vaccine Mandate Faces Headwinds

Biden's workplace vaccine mandate faces headwinds - POLITICO

Source: Politico, by Rebecca Rainey

President Joe Biden’s surprise order for the Labor Department to issue mandatory vaccine rules for large companies is already facing headwinds from businesses, conservative governors and even his union allies.

Management-side attorneys say they are fielding frenzied calls from companies with questions over what the rules requiring them to verify that their workers are vaccinated or tested weekly for Covid-19 will actually entail and whether the business or unvaccinated employees will have to pay for the testing.

Unions have been treading a fine line over the new policy, arguing that workers and labor should have a say in any vaccine mandate policy — required by the federal government or not — while also strongly urging their members to get the shot.

And Republican governors Brian Kemp of Georgia and Kristi Noem of South Dakota said they plan to challenge the mandate. Florida Gov. Ron DeSantis said he opposes “mandates of any kind.”

All of that underscores how difficult it will be for the administration to quickly implement a sweeping policy that will affect some 80 million private sector workers.

“I think this redefines ‘ideas are simple, execution is hard,’” said attorney Michael Lotito, who represents businesses for law firm Littler Mendelson.

“What we have right now is chaos,” Lotito added, “because of the unintended consequences of making such an announcement where there is no clarity with respect to a gargantuan number of questions that have been left open.”

The new emergency rules were announced Thursday as part of a new six-part effort from Biden to increase the vaccination rate in the U.S. as he seeks to tamp down criticism over the administration’s handling of a surge in coronavirus cases related to the Delta variant. Only about 53 percent of the population is currently fully vaccinated, according to the Centers for Disease Control and Prevention.

The rules, which will be fleshed out by administration officials, will be the first federal Covid-19-specific safety mandates to impact everyday workplaces. Until now, most employers outside the health care industry have been subject to optional safety guidelines.

The emergency temporary standard will require companies with more than 100 workers to verify that their workforce is vaccinated or get tested weekly for Covid-19. Employers who break the rules could face fines of $14,000 per violation, according to the White House.

But there are many questions about what the scope of the rule will be. For instance, does the 100-employee threshold apply to one worksite, or an entire company? Does the company have to pay for testing or does the employee?

Implementing a rapid testing program like the one envisioned under Biden’s plan is logistically difficult and costly, said Ian Schaefer, chair of Loeb and Loeb’s employment and labor practice in New York.

“It’s millions of dollars a year to any size company. I’ve seen companies do it before Biden issued his order and it’s incredibly burdensome and time consuming and may not even guarantee health and safety in the way that mandating vaccines would,” Schaefer said.

“The administration is incredibly difficult, and it’s imperfect, with respect to making sure that the testing is timely, that people who are testing actually don’t have COVID,” he added.

It’s also unclear how soon the rule will go into effect — standards issued by federal agencies typically take several weeks to write and go through executive branch review.

However, the Department of Labor has been working on the standard for at least a week, according to two people familiar with the matter.

The rules will be enforced by the federal Occupational Safety and Health Administration, and are expected to be issued in the coming weeks, an administration official said Thursday. But the agency took several months to issue a Covid-19 health care emergency temporary standard earlier this year and spent weeks meeting with stakeholders on the rule.

Business groups are expected to object to some aspects of the vaccine emergency rule.

Unions have also warned that mandatory vaccination policies in the workplace need to be negotiated between workers and their employers, raising the possibility of friction and delays in individual workplaces.

“Everyone should be vaccinated — as one step in stopping the pandemic,” AFL-CIO President Liz Shuler said in response to Biden’s Covid-19 plan. “Workers and unions should have a voice in shaping these policies.”

The mandate also faces a fight in the court of public opinion. A recent Washington Post-ABC News poll found that less than half of Americans support workplace vaccine mandates.

Despite the uncertainties, a legal fight does not seem likely to come from big business players like the Chamber of Commerce or the National Retail Federation.

“We appreciate the administration’s commitment to ensuring workplaces are safe despite the ongoing challenges of the pandemic,” said Edwin Egee, vice president of government relations and workforce development at the NRF in response to the announcement. “We look forward to working with the Labor Department as it promulgates this rule.”

The Chamber of Commerce said in a statement that it will “carefully review the details of the executive orders and associated regulations” and will work to ensure that employers have “resources, guidance, and flexibility” to comply with the requirements.

The Equal Employment Opportunity Commission has already clarified that employers can require their staffs to get vaccinated, so long as they provide accommodations for workers who say they can’t get the shot because of their religious beliefs or a disability. Businesses can tell workers to stay home if they can’t be vaccinated for one of those reasons, and workers could be fired if their employer is unable to accommodate remote work, attorneys say.

But proving that it would be an “undue hardship” to provide an accommodation can be difficult, and attorneys say they are skeptical that arguing the cost of providing testing is too expensive would meet that threshold.

Important Employer Compliance Requirement Due By 10/15

Employer compliance beyond CARES and FFRCA: Don't forget the basics |  BenefitsPRO

Source: Word & Brown, by Paul Roberts

Employers (of any size) providing prescription drug coverage benefits must distribute an annual notice to all Medicare-eligible individuals by October 15th – including both employees and dependents. This important notice helps Medicare-eligible individuals make decisions about their health plans, drug coverage, and/or Medicare enrollment, so they may attain the best coverage for their health needs and avoid potential noncompliance penalties in the Medicare space.

When a person becomes eligible for Medicare (usually at age 65), that person must generally enroll for Medicare coverage upon initial eligibility, or a noncompliance penalty could be on the horizon. However, many can delay this requirement (and its related penalty) by attaining qualified (non-COBRA) coverage through a qualified group health plan in lieu of Medicare.

In order for that coverage to be qualified, the employer’s coverage must be considered “creditable.”  That is, the (non-COBRA) group coverage must provide benefits that are at least equal to (or richer than) the benefits provided by Medicare.

Employers must disclose to all Medicare-eligible individuals whether the drug benefits provided in the employer’s plan are “creditable” or “non-creditable,” when compared to Medicare Part D’s drug benefits. Employers must distribute a notice describing this disclosure each year before October 15th, ahead of Medicare’s Annual Election Period (AEP). During this AEP, Medicare beneficiaries and Medicare-eligible persons can enroll in, or change, Medicare Advantage plans, Medigap plans, or Medicare Part D Prescription Drug coverage plans. The information contained in the employer’s disclosure helps the Medicare-eligible person make decisions about enrollment in Medicare Part D drug plans.

A Medicare-eligible person who does not enroll in Medicare Part D Prescription Drug Coverage when first eligible will face an eventual late enrollment penalty for the entire time he or she is enrolled in Medicare Part D coverage, unless that person has qualifying “creditable” drug coverage from an employer plan. The penalty is assessed upon any person who does not maintain creditable coverage for more than 62 days after his/her initial Medicare enrollment period.

Employers are likely to turn to you, as their health insurance broker, for help determining whether the prescription drug coverage they sponsor is creditable. They may also seek an understanding of what to distribute to employees, model notices that should be used – and when everything should be distributed. Word & Brown has you covered.

Medicare Part D Charts – Creditable or Non-Creditable Designation

We’ve surveyed our carrier partners and have placed creditable/non-creditable designations in easy-to-reference charts for all carriers’ Small Group plans and Large Group plans. Refer to these charts to determine whether the coverage sponsored by the employer is creditable or non-creditable:

Creditable Coverage Model Notice

The Centers for Medicare & Medicaid Services (CMS) provide model notices to meet these distribution requirements, along with additional information on the required distribution. The model notices must be customized by the employer, as indicated on the model notices, before the employer releases them to Medicare-eligible individuals. There are different notices for creditable coverage and non-creditable coverage. The forms are also available in Spanish.

CMS Online Reporting Requirement for Employers

Employers providing prescription drug coverage to Medicare-eligible individuals must also submit an online disclosure to CMS annually, and upon any change that affects creditable status. The disclosure is due no later than 60 days from the beginning of a plan year, within 30 days after the termination of prescription drug coverage, or within 30 days after any change in creditable coverage status. This disclosure is required whether the employer-sponsored group coverage pays primary or secondary to Medicare coverage.

For help on calculating group size relating to “Medicare Primary” vs “Medicare Secondary,” COBRA, and the Affordable Care Act (ACA), refer to Word & Brown’s Group Count Reference (CA) or Group Count Reference (NV).

For additional support, contact WBCompliance via phone at 866.375.2039 or by email at

Health Care Unions Defending Newsom From Recall Will Want Single-Payer Payback

Single-payer activists rally against the recall in front of the California Capitol on June 15. (Angela Hart/California Healthline)

Source: Kaiser Health News, by Angela Hart

Should Gavin Newsom survive the Republican-driven attempt to oust him from office, the Democratic governor will face the prospect of paying back supporters who coalesced behind him.

And the leaders of California’s single-payer movement will want their due.

Publicly, union leaders say they’re standing beside Newsom because he has displayed political courage during the covid-19 pandemic by taking actions such as imposing the nation’s first statewide stay-at-home order. But behind the scenes, they are aggressively pressuring him to follow through on his 2018 campaign pledge to establish a government-run, single-payer health care system.

“I expect him to lead on California accomplishing single-payer and being an example for the rest of the country,” said Sal Rosselli, president of the National Union of Healthcare Workers, which is urging Newsom to get federal permission to fund such a system.

Another union, the California Nurses Association, is pushing Newsom to back state legislation early next year to do away with private health insurance and create a single-payer system. But “first, everyone needs to get out and vote no on this recall,” said Stephanie Roberson, the union’s lead lobbyist.

“This is about life or death for us. It’s not only about single-payer. It’s about infection control. It’s about Democratic and working-class values,” she said. “We lose if Republicans take over.”

Together, the unions have made hundreds of thousands of dollars in political contributions, funded anti-recall ads and phone-banked to defend Newsom. The latest polling indicates Newsom will survive Tuesday’s recall election, which has become a battle between Democratic ideals and Republican angst over government coronavirus mandates. The Democratic Party closed ranks around the governor early and kept well-known Democratic contenders off the ballot, leaving liberal voters with little choice other than Newsom.

“This is a crucial moment for Newsom, and for his supporters who are lining up behind him,” said Mark Peterson, a professor of public policy, political science and law at UCLA who specializes in the politics of health care. “They’re helping him stay in office, but that comes with an expectation for some action.”

But it’s not clear that Newsom — who will face competing demands to pay back other supporters pushing for stronger action on homelessness, climate change and public safety — could deliver such a massive shift.

Reorganizing the health system under a single-payer financing model would be tremendously expensive — around $400 billion a year — and difficult to achieve politically, largely because it would require tax increases.

The concept already faces fierce opposition from some of Newsom’s strongest supporters, including insurer Blue Shield of California and the California Medical Association, which represents doctors.

No state has a single-payer system. Vermont tried to implement one, but its former governor, a Democrat, abandoned his plan in 2014 partly because of opposition to tax increases. California would not only need to raise taxes, but would also likely have to seek voter approval to change the state constitution, and get permission from the federal government to use money allocated for Medicare and Medicaid to help fund the new system.

The last big push for single-payer in California ended in 2017 because it did not adequately address financing and other challenges. Leading up to the 2018 gubernatorial election, Newsom campaigned on single-payer health care, telling supporters “you have my firm and absolute commitment as your next governor that I will lead the effort to get it done,” and “single-payer is the way to go.”

In office, though, Newsom has distanced himself from that promise as he has expanded the existing health system, which relies on a mix of public and private insurance company payers. For instance, he and Democratic lawmakers imposed a health insurance mandate on Californians and expanded public coverage for low-income people, both of which enrich health insurers.

Newsom has, however, convened a commission to study single-payer and in late May wrote to President Joe Biden, asking him to work with Congress to pass legislation giving states freedom and financing to establish single-payer systems. “California’s spirit of innovation is stifled by federal limits,” Newsom wrote.

Newsom’s recall campaign, asked about his stance on single-payer, referred questions to his administration. The governor’s office said in prepared comments that Newsom remains committed to the idea.

“Governor Newsom has consistently said that single-payer health care is where we need to be,” spokesperson Alex Stack wrote. “It’s just a question of how we get there.”

Stack also highlighted a new initiative that will build up the state’s public health insurance program, Medi-Cal, saying it “paves a path toward a single-payer principled system.”

Activists say Newsom has let them down on single-payer but are standing behind him because he represents their best shot at obtaining it. However, some say they’re not willing to wait long. If Newsom doesn’t embrace single-payer soon, liberal activists say, they will look for a Democratic alternative when he comes up for reelection next year.

“Newsom is an establishment candidate, and we as Democrats aren’t shy about ripping the endorsement out from under someone who doesn’t share our values,” said Brandon Harami, Bay Area vice chair of the state Democratic Party’s Progressive Caucus, who opposes the recall. “Newsom has been completely silent on single-payer. A lot of us are really gunning to see some action on his part.”

State Assembly member Ash Kalra (D-San Jose), who also opposes the recall, will reintroduce his single-payer billAB 1400, in January after he paused it earlier this year to work on a financing plan. Its chief sponsor is the California Nurses Association.

Using lessons learned from the failed 2017 attempt to pass single-payer legislation, the nurses union is deploying activists to pressure state and local lawmakers into supporting the bill. Resolutions have been approved or are pending in multiple cities.

“This is an opportunity for California to lead the way on health care,” Los Angeles City Council member Mike Bonin said before an 11-0 vote backing Kalra’s single-payer bill in late August.

Kalra argued that support from Los Angeles shows his bill is gaining momentum. He is also preparing a new strategy to take on doctors, hospitals, health insurers and other health industry players that oppose single-payer: highlighting their profits.

“They are the No. 1 obstacle to this passing,” Kalra said. “They’re going to do whatever they can to discredit me and this movement, but I’m going to turn the mirror around on them and ask why we should continue to pay for wild profits.”

An industry coalition called Californians Against the Costly Disruption of Our Health Care was instrumental in killing the 2017 single-payer bill and is already lobbying against Kalra’s measure. The group again argues that single-payer would push people off Medicare and private employer plans and result in less choice in health insurance.

Single-payer would “force these millions of Californians who like their health care into a single new, untested government program with no guarantee they could keep their doctor,” coalition spokesperson Ned Wigglesworth said in a statement.

Bob Ross, president and CEO of the California Endowment, a nonprofit that works to expand health care access, is on Newsom’s single-payer commission. He said it will work through “tension” in the coming months before issuing a recommendation to the governor on the feasibility of single-payer.

“We have a camp of single-payer zealots who want the bold stroke of getting to single-payer tomorrow, and the other approach that I call bold incrementalism,” Ross said. “I’m not ruling out any bold stroke on single-payer; I would just want to know how we get it done.”

ICU Beds Filling Up In California’s Central Valley Amid COVID Surge, Triggering Hospital Order

ICU beds in San Joaquin Valley drop to concerningly low levels - Los  Angeles TimesSource: KTLA, by Associated Press

Hospitals in the heart of California’s Central Valley are running out of beds in their intensive care units, state officials announced Friday, as a more contagious version of the coronavirus continues to spread primarily among the unvaccinated population.

Hospitals in the eight-county San Joaquin Valley region have had fewer than 10% of staffed adult ICU beds for three consecutive days. State officials labeled it a “surge,” triggering special rules announced last month that require nearby hospitals to accept transfer patients.

In Fresno County and neighboring counties, the number of confirmed and suspected coronavirus patients in hospitals is more than double what it was four weeks ago, the Fresno Bee reported.

In San Joaquin County, new virus cases and the number of people admitted to hospitals has surpassed the peak numbers of cases and patients during last summer’s surge, according to the county health officer. But a spokeswoman for the county’s Office of Emergency Services said the county had enough hospital beds to avoid transferring patients out of the county as of Friday.

If the problem gets worse and ICU capacity falls to zero, the state says hospitals across California must also accept transfer patients.

Statewide, new coronavirus cases have declined following a surge attributed to the delta variant, a more contagious and dangerous version of the virus. Tuesday, Gov. Gavin Newsom announced more than 80% of Californians 12 and older have received at least one dose of the coronavirus vaccine — putting California among the highest vaccine rates in the country.

But coronavirus-related hospitalizations in the state have continued to climb. As of Thursday, 8,630 people were hospitalized because of the coronavirus across the state, more than five times higher the number of people hospitalized on July 1.

“This is still primarily, overwhelmingly, a pandemic of the unvaccinated,” Newsom said Tuesday.

COVID Medical Bills Are About to Get Bigger

Covid Medical Bills Are About to Get Bigger - The New York TimesSource: The New York Times, by Sarah Kliff

Americans will most likely pay significantly more for COVID medical care during this new wave of cases — whether that is a routine coronavirus test or a lengthy hospitalization.

Earlier in the pandemic, most major health insurers voluntarily waived costs associated with a COVID treatment. Patients did not have to pay their normal copayments or deductibles for emergency room visits or hospital stays.

Most COVID tests were free, too.

The landscape has since changed, as the pandemic persists into its second year. Federal law still requires insurers to cover testing at no cost to the patient when there is a medical reason for seeking care, such as exposure to the disease or a display of symptoms. But more of the tests sought now do not meet the definition of “medical reason” and are instead for monitoring.

And insurers are now treating COVID more like any other disease, no longer fully covering the costs of care. Some businesses, like Delta Air Lines, are planning to charge unvaccinated employees higher rates for insurance, citing in part the high hospitalization costs for COVID cases.

“Insurers are confronting the question about whether the costs of COVID treatment should fall on everyone, or just the individuals who have chosen not to get a vaccine,” said Cynthia Cox, a vice president at the Kaiser Family Foundation who has researched how insurers are covering COVID treatment.

The federal rules that make coronavirus testing free include exemptions for routine workplace and school testing, which has become more common as students head back to the classroom and as companies mandate regular testing for unvaccinated workers.

Because insurers are not required to cover that regular testing, some patients have already received testing bills as high as $200 for routine screenings, according to documents that patients have submitted to a New York Times project tracking the costs of COVID testing and treatment.

Some of the highest bills, however, will probably involve COVID patients who need extensive hospital care now that most insurers no longer fully cover those bills. Seventy-two percent of large health plans are no longer making COVID treatment free for patients, a recent study from the Kaiser Family Foundation found.

This includes Blue Cross Blue Shield of Florida, the largest health plan in a state experiencing one of the country’s worst outbreaks. On Wednesday, Florida Blue began requiring patients to pay their normal deductibles and copayments for COVID treatment. Toni Woods, a spokeswoman, said the plan was now focused on encouraging vaccinations.

“When the COVID-19 pandemic began last year, we implemented several emergency provisions to temporarily help our members,” she said in a statement. “Medical diagnostic testing for COVID-19 as well as vaccinations continue to be available to members at $0 cost share.”

Oscar Health, which sells coverage in Florida and 14 other states, also ended free COVID treatment this week. It cited the widespread availability of the vaccine as a key reason.

“We started waiving cost sharing for COVID-19 treatment at the peak of the pandemic in 2020, when there were few options available for those who fell ill with the virus,” said Jackie Khan, an Oscar spokeswoman. “We believe that the COVID vaccine is our best way to beat this pandemic, and we are committed to covering it and testing at $0 for our members.”

The new policies generally apply to all patients, including the vaccinated; people who get sick with a breakthrough infection; and children under 12, who are not yet eligible for the vaccine.

“If you have a small kid who gets COVID at school and ends up at the ICU, that family is going to now be stuck with the bill even though that patient did not have the ability to get vaccinated,” said Dr. Kao-Ping Chua, a pediatrician at the University of Michigan who researches COVID care costs.

The average COVID hospitalization costs approximately $40,000, researchers have found. A lengthy hospital stay — one that requires time in the intensive care unit, or a transfer by air ambulance — can cost many multiples more. Most insured patients will not pay that entire bill. They will face whatever share they owe through deductibles and copayments.

Chua and his colleagues published research this summer finding that, among patients who had to pay a share of their COVID hospitalization, the average costs were $3,800.

“There were some patients where it was $10,000 and others where it was $500,” he said. “It gives you some semblance of what things will now look like without the waivers.”

Surprise bills for routine COVID testing could be smaller but more common, as schools and workplaces increasingly rely on regular screening to prevent coronavirus from spreading.

At many workplaces, unvaccinated workers must submit to monitoring at least weekly. Some employers, including the federal government, plan to fully cover the costs of those tests. But others, including some hotels and universities, will ask unvaccinated workers to bear some or all of the testing costs.

Rebecca Riley recently received a $200 bill from a laboratory with an unfamiliar name. When she called to inquire about the charge, she learned it was a fee for a COVID test. Her son, a high school student, is regularly tested at his Los Angeles-area high school.

“I didn’t expect to get any bills,” she said. “I feel stupid, but I’d heard the tests were free.”

Riley contacted her insurer about the charge and it agreed to pay the full amount. But she now worries about future surprise testing bills.

“I really feel for the families that won’t be able to pay,” she said.

Pfizer COVID Booster Shots Will Likely Be Ready Sept. 20, But Moderna May Be Delayed, Fauci Says

Pfizer Covid booster shots likely ready Sept. 20, Anthony Fauci saysSource: CNBC, by Jacob Pramuk

The U.S. will likely start to widely distribute Pfizer Covid-19 booster shots during the week of Sept. 20, but the rollout for Moderna’s vaccine could be delayed, White House chief medical advisor Dr. Anthony Fauci said Sunday.

The Biden administration has announced plans to offer third doses to people who received the Pfizer and Moderna shots, pending approval from public health officials. The U.S. recommends an additional shot eight months after the second dose.

Only the Pfizer vaccine booster may get Food and Drug Administration and Centers for Disease Control and Prevention approval in time for a rollout the week of Sept. 20, Fauci said on CBS’ “Face the Nation.” People who received Moderna shots may have to hold off for longer as the company waits for regulators to sign off on a third dose.

“Looks like Pfizer has their data in, likely would meet the deadline,” the director of the National Institute of Allergy and Infectious Diseases told CBS. “We hope that Moderna would also be able to do it, so we could do it simultaneously.”

“But if not, we’ll do it sequentially,” he continued. “So the bottom line is, very likely, at least part of the plan will be implemented, but ultimately the entire plan will be.”

Later Sunday, Fauci told CNN that for people who got two doses of the Moderna vaccine, “it’s better to wait” for a third Moderna dose than get a Pfizer shot. He noted that the U.S. plans to release data in the coming weeks on mixing vaccines from different manufacturers.

The Pfizer-BioNTech Covid-19 vaccine is the most widely administered in the U.S. More than 95 million people have received the full two-shot regimen, according to CDC data.

About 66 million people have been fully vaccinated with the Moderna shot. Meanwhile, about 14 million people have received the one-dose Johnson & Johnson shot. Regulators have not announced plans for a J&J booster.

In calling for third Pfizer and Moderna doses, U.S. health officials cited CDC data that found protection against infection waned several months after the second shot. More than 1.3 million people have received an additional shot after the U.S. authorized them for certain immunocompromised individuals, according to the CDC.

On Sunday, White House chief of staff Ron Klain told CNN’s “State of the Union” that the administration will have booster shots “ready to go” whenever regulators approve them for wider use.

An FDA advisory panel will review Pfizer’s application for a booster on Sept. 17, only three days before shots are supposed to start.

The Biden administration’s booster plan has sparked criticism within the U.S. and around the world. The World Health Organization has urged wealthy countries with higher vaccination rates to hold off on additional shots until poorer countries can give more people first vaccine doses.

As the virus spreads around the globe, it raises the prospect of new — and potentially more dangerous — variants emerging.

The White House has defended its booster plan, citing U.S. donations of vaccine doses to other countries. Last month, Fauci told CNBC that the U.S. has given 120 million doses to 80 countries.

“We are doing both,” he said of vaccinating Americans and people around the world.

Medicare Trustees Project Hospital Fund To Run Out In 2026, Same Deadline As Year Before

Medicare trustees project hospital fund to run out in 2026, same deadline  as year before | FierceHealthcare

Source: Fierce Healthcare, by Robert King

Medicare’s insurance trust fund that pays hospitals is expected to run out of money in 2026, the same projection as last year, according to a new report from Medicare’s board of trustees.

The report, released Tuesday, found Medicare spent $925.8 billion in 2020 and served 62.6 million people. It found that the COVID-19 pandemic had a major impact on the short-term financing for the program, but the financial status overall of the fund hasn’t significantly changed.,

“The amount of payroll taxes expected to be collected by the [hospital insurance] trust fund was greatly reduced due to the economic effects of the pandemic on labor markets,” the report said. “Spending was directly affected by the coverage of testing and treatment of the disease.”

Several regulatory and legislative policies also impacted spending, including payments for inpatient admissions related to COVID-19, which increased by 20%.

But major declines in spending for non-COVID-19 care declined dramatically due in part to a postponement of elective procedures, helping offset some of the increases in spending.

“Because of the large wave of COVID-19 cases in early 2021, non-COVID-related spending is estimated to be lower than previously expected for the beginning of the year,” the report added. “As care that was reduced or deferred returns, the trend in the latter part of 2021 is slightly higher than anticipated previously.”

Hospital insurance trust fund expenditures exceed income by $60.4 billion due to a massive amount of accelerated and advance payments. The Centers for Medicare & Medicaid Services sent out $100 billion in advance and accelerated payments to providers at the onset of the pandemic to plug financial shortfalls.

However, this money is expected to be repaid by providers this year and in 2022, “resulting in a small deficit in 2021 and a surplus in 2022.”

“After that, the trustees project deficits in all future years until the trust fund becomes depleted in 2026,” the report added.

It found that tax income for the hospital insurance trust fund and other dedicated revenue will “fall short” of expenditures in future years.

In light of this continued shortfall, Congress needs to quickly move to address the disparities.

“The sooner solutions are enacted, the more flexible and gradual they can be,” the report said. “The early introduction of reforms increases the time available for affected individuals and organizations—including healthcare providers, beneficiaries and taxpayers—to adjust their expectations and behavior.”

It remains unclear how Congress would curb Medicare spending. Democrats are seeking to expand Medicare by adding dental, vision and hearing benefits as part of a $3.5 trillion infrastructure package. Democrats also aim to give Medicare negotiation authority to lower drug prices to help pay for the expansion.

The Medicare Payment Advisory Commission, which advises Congress on Medicare policy, has recommended that lawmakers change how Medicare Advantage payments are calculated and result in a 2% cut to the payments. The cuts would result in $82 billion in savings from 2021 through 2029 and could go toward the fund, according to a MedPAC report.

Actuaries Project Future Virus Surges, End Of Regulatory Flexibility Key Drivers In 2022 Rates

Fed's Rosengren Says 2022 Rate Hike in Play as Job Market Heals - Bloomberg

Source: Fierce Healthcare, by Robert King

Uncertainty over future surges of COVID-19 and the end of regulatory flexibilities are going to be major drivers for 2022 premiums on the individual and small group markets, a new actuary report finds.

The report, released Thursday (PDF) by the American Academy of Actuaries, finds insurers face major uncertainties like the end of the public health emergency and the fate of enhanced subsidies for coverage on the Affordable Care Act’s (ACA’s) insurance exchanges.

“Greater degrees of uncertainty could lead to more conservative assumptions and risk margins for some insurers,” the report said. “Alternatively, carriers might lower risk margins, seeing an opportunity to capitalize on the increased enrollment due to the [American Rescue Plan Act] subsidies.”

Because of the high level of uncertainty surrounding the pandemic last year, most insurers included no COVID-19 adjustments in their rates. However, insurers are likely to include such adjustments because there is more information on how the pandemic has affected healthcare use and spending, but these adjustments are likely to not be material, the report said.

But there could be some other major unknowns for insurers that could factor into their rates.

For example, it remains unclear whether new waves of the virus will emerge later in 2021 or next year on a regional or national level. The more transmissible delta variant has caused cases of the virus to surge over the past few months.

“New COVID-19 variants and waves in 2021 or 2022 may influence regional variations in hospitalization utilization, increase the need for vaccine booster shots and impact how and where members seek or delay care,” the report said.

The pandemic likely won’t just affect healthcare utilization but also the risk pool for insurers.

The individual market’s risk pool is likely to be very different than the one that existed in 2020 due to several factors that include larger premium tax credits that expire after the 2022 coverage year.

Another key issue is what will happen with the COVID-19 public health emergency, which prevents states from dropping residents off the Medicaid rolls. If the emergency ends this year, this will cause Medicaid eligibility determinations to resume and move “many people off Medicaid rolls and into either the individual market or the uninsured population,” the report said.

Any increases the ACA’s insurance exchanges see for the 2022 coverage year could be offset by people leaving the individual market, either by becoming eligible for Medicaid or by obtaining employer-sponsored insurance because of an economic recovery, the actuaries say.

“These changes will depend on the characteristics of those leaving and those entering the market,” the report added.

Insurers are also likely factoring in the calculation of medical loss ratio (MLR) rebates. The ACA requires insurers to spend 85% of every premium dollar on medical claims and the rest on administration. If claims were below premiums, insurers are required to offer a rebate to consumers for the difference.

MLRs are calculated on a three-year average, and, because 2018 and 2019 had major MLR rebates, it could “increase the potential for 2020 rebates as well,” the actuaries said. “Issuers may consider projected MLR rebates when setting their 2022 rates, especially given the level of MLR rebates expected for 2020. This consideration could be given additional weight if the issuers anticipate owing 2020 rebates given their expectations regarding the net impact of COVID-19.”

Telehealth’s Limits: Battle Over State Lines and Licensing Threatens Patients’ Options

Telehealth's Limits: Battle Over State Lines and Licensing Threatens  Patients' Options | Kaiser Health News

Source: Kaiser Health News, by Julie Appleby

If you live in one state, does it matter that the doctor treating you online is in another? Surprisingly, the answer is yes, and the ability to conduct certain virtual appointments may be nearing an end.

Televisits for medical care took off during the worst days of the pandemic, quickly becoming commonplace. Most states and the Centers for Medicare & Medicaid Services temporarily waived rules requiring licensed clinicians to hold a valid license in the state where their patient is located. Those restrictions don’t keep patients from visiting doctors’ offices in other states, but problems could arise if those same patients used telemedicine.

Now states are rolling back many of those pandemic workarounds.

Johns Hopkins Medicine in Baltimore, for example, recently scrambled to notify more than 1,000 Virginia patients that their telehealth appointments were “no longer feasible,” said Dr. Brian Hasselfeld, medical director of digital health and telemedicine at Johns Hopkins. Virginia is among the states where the emergency orders are expiring or being rolled back.

At least 17 states still have waivers in effect, according to a tracker maintained by the Alliance for Connected Care, a lobbying group representing insurers, tech companies and pharmacies.

As those rules end, “it risks increasing barriers” to care, said Hasselfeld. Johns Hopkins, he added, hosted more than 1 million televisits, serving more than 330,000 unique patients, since the pandemic began. About 10% of those visits were from states where Johns Hopkins does not operate facilities.

The rollbacks come amid a longer and larger debate over states’ authority around medical licensing that the pandemic — with its widespread adoption of telehealth services — has put front and center.

“Consumers don’t know about these regulations, but if you all of a sudden pull the rug out from these services, you will definitely see a consumer backlash,” said Dr. Harry Greenspun, chief medical officer for the consultancy Guidehouse.

Still, finding a way forward pits high-powered stakeholders against one another, and consumers’ input is likely to be muted.

State medical boards don’t want to cede authority, saying their power to license and discipline medical professionals boosts patient safety. Licensing is also a source of state revenue.

Providers have long been split on whether to change cross-state licensing rules. Different state requirements — along with fees — make it cumbersome and expensive for doctors, nurses and other clinicians to get licenses in multiple states, leading to calls for more flexibility. Even so, those efforts have faced pushback from within the profession, with opposition from other clinicians who fear the added competition that could come from telehealth could lead to losing patients or jobs.

“As with most things in medicine, it’s a bottom-line issue. The reason telehealth has been blocked across state lines for many years related fundamentally to physicians wanting to protect their own practices,” said Greenspun.

But the pandemic changed the equation.

Even though the initial spike in telehealth visits has eased, utilization remains 38 times higher than before the pandemic, attracting not only patients, but also venture capitalists seeking to join the hot business opportunity, according to a report from consulting firm McKinsey and Co.

Patients’ experience with televisits coupled with the growing interest by investors is focusing attention on this formerly inside-baseball issue of cross-state licensing.

Greenspun predicts consumers will ultimately drive the solution by “voting with their wallets,” aided by giant, consumer-focused retailers like Amazon and Walmart, both of which in recent months made forays into telemedicine.

In the short term, however, the focus is on both the protections and the barriers state regulations create.

“The whole challenge is to ensure maximum access to health while assuring quality,” said Barak Richman, a Duke University law professor, who said laws and policies haven’t been updated to reflect new technological realities partly because state boards want to hang onto their authority.

Patients and their doctors are getting creative, with some consumers simply driving across state lines, then making a Zoom call from their vehicle.

“It’s not ideal, but some patients say they are willing to drive a mile or two and sit in a parking lot in a private space and continue to get my care,” said Dr. Shabana Khan, director of telepsychiatry at NYU Langone Health’s department of child and adolescent psychiatry and a member of the American Psychiatric Association’s Telepsychiatry Committee. She and other practitioners ask their patients about their locations, mainly for safety reasons, but also to check that they are in-state.

Still, for some patients, driving to another state for an in-person or even a virtual appointment is not an option.

Khan worries about people whose care is interrupted by the changes, especially those reluctant to seek out new therapists or who cannot find any clinicians taking new patients.

Austin Smith hopes that doesn’t happen to him.

After initial treatment for what he calls a “weird flavor of cancer” didn’t help reduce his gastrointestinal stromal tumors, he searched out other experts, landing in a clinical trial. But it was in San Diego and the 28-year-old salesman lives in Phoenix.

Although he drives more than five hours each way every couple of months for treatment and to see his doctors, he does much of his other follow-up online. The only difference is “if I was in person, and I said I was hurting here, the doctor could poke me,” he said.

And if the rules change? He’ll make the drive. “I’ll do anything to beat this,” he said of his cancer.

But will doctors, whose patients have spent the past year or more growing comfortable with virtual visits, also be willing to take steps that could likely involve extra costs and red tape?

To get additional licenses, for instance, practitioners must submit applications in every state where their patients reside, each of which can take weeks or months to process. They must pay application fees and keep up with a range of requirements such as continuing education, which vary by state.

States say their traditional role as overseer ensures that all applicants meet educational requirements and pass background checks. They also investigate complaints and argue there’s an advantage to keeping local officials in charge.

“It’s closer to home,” said Lisa Robin, chief advocacy officer with the Federation of State Medical Boards. “There’s a remedy for residents of the state with their own state officials.”

Doctor groups such as the American Medical Association agree.

Allowing a change that doesn’t put centralized authority in a patient’s home state would raise “serious enforcement issues as states do not have interstate policing authority and cannot investigate incidents that happen in another state,” said then-AMA President-elect Jack Resneck during a congressional hearing in March.

But others want more flexibility and say it can be done safely.

Hasselfeld, at Johns Hopkins, said there is precedent for easing multistate licensing requirements. The Department of Veterans Affairs, for example, allows medical staffers who are properly licensed in at least one state to treat patients in any VA facility.

The Alliance for Connected Care and other advocates are pushing states to extend their pandemic rules. A few have done so. Arizona, for example, made permanent the rules allowing out-of-state medical providers to practice telemedicine for Arizona residents, as long as they register with the state and their home-state license is in good standing. Connecticut’s similar rules have now been stretched until June 2023.

The alliance and others also back legislation stalled in Congress that would temporarily allow medical professionals licensed in one state to treat — either in person or via televisits — patients in any other state.

Because such fixes are controversial, voluntary interstate pacts have gained attention. Several already exist: one each for nurses, doctors, physical therapists and psychologists. Proponents say they are a simple way to ensure state boards retain authority and high standards, while making it easier for licensed medical professionals to expand their geographic range.

The nurses’ compact, enacted by 37 states and Guam, allows registered nurses with a valid license in one state to have it recognized by all the others in the pact.

A different kind of model is the Interstate Physician Licensure Compact, which has been enacted by 33 states, plus the District of Columbia and Guam, and has issued more than 21,000 licenses since it began in 2017, said Robin, of the Federation of State Medical Boards.

While it speeds the paperwork process, it does not eliminate the cost of applying for licenses in each state.

The compact simplifies the process by having the applicant physician’s home state confirm his or her eligibility and perform a criminal background check. If the applicant is eligible, the home state sends a letter of qualification to the new state, which then issues a license, Robin said. Physicians must meet all rules and laws in each state, such as requirements for continuing medical education. Additionally, they cannot have a history of disciplinary actions or currently be under investigation.

“It’s a fairly high bar,” said Robin.

Such compacts — especially if they are bolstered by new legislation at the federal level — could help the advances in telehealth made during the pandemic stick around for good, expanding access to care for both mental health services and medical care across the U.S. “What’s at stake if we get this right,” said Richman at Duke, “is making sure we have an innovative marketplace that fully uses virtual technology and a regulatory system that encourages competition and quality.”

Last Updated 09/22/2021

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