15 Million People Could Lose Coverage After Public Health Emergency Ends, Report Says

Almost 90% of pandemic-era Medicaid enrollees at risk of losing coverage |  Modern HealthcareSource: Becker’s Hospital Review, by Nick Moran

A new report by the Urban Institute, funded by Robert Wood Johnson Foundation, anticipates that 15 million people could be out of Medicaid coverage when the pandemic public health emergency ends.

Medicaid enrollment initially swelled as a result of early pandemic joblessness and continuous coverage requirement of the Families First Coronavirus Response Act, according to the Sept. 15 report.

With the public health emergency in place through the end of 2021, researchers estimated that Medicaid enrollment could grow to 17 million new members since the start of the pandemic. That would bring the total number of Medicaid beneficiaries under the age of 65 to 76.3 million.

Should the public health emergency conclude at the end of 2021 as anticipated, however, 9 million adults and 6 million children could lose coverage through 2022, according to the report.

The report highlighted possible ways to tamper disenrollment, such as making American Rescue Plan Act Marketplace premium tax credits permanent, which would assist nearly a third of adults at risk of losing coverage.

Over half (57 percent) of children at risk of losing coverage would qualify for Children’s Health Insurance Program coverage. An additional 9 percent could be eligible for Marketplace coverage via tax credits.

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 ComplianceSupport@wordandbrown.com.

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.

CMS Delays Enforcement Of Key Parts Of Price Transparency Rule By 6 Months

CMS delays enforcement of key parts of price transparency rule by 6 months  | FierceHealthcare

Source: Fierce Healthcare, by Robert King

The Biden administration has delayed enforcement of key parts of a major insurer price transparency rule by six months until July 1, 2022, to give plans more time to comply.

The Centers for Medicare & Medicaid Services (CMS) announced the change in a new guidance released Friday focusing on the final price transparency rule released last October under the Trump administration. The guidance focuses on a requirement that certain health plans disclose online their in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for certain items and services.

The agency said it recognizes the “considerable time and effort required to make the machine-readable files available in the form and manner required in the [regulations].”

Even though the rule goes into effect Jan. 1, 2022, CMS will not enforce the requirement that plans publicly disclose their in-network, out-of-network amounts and billed charges for plan years until July 1.

Any plan year that begins after July 1 must post the files in the “month in which the plan year (in the individual market, policy year) begins.”

The plan also gave a hint on the requirements plans will face when they must submit information on drug costs and pharmacy benefits. CMS will issue regulations in the near future on the reporting requirements, but it recognizes “the significant operational challenges that plans and issuers may encounter in complying with these reporting requirements by the statutory deadlines set forth in the statute.”

CMS said it will defer enforcement of the first requirement for reporting on Dec. 27, 2021, and the second deadline of reporting on June 1, 2022.

“Until regulations or further guidance is issued, the departments strongly encourage plans and issuers to start working to ensure that they are in a position to be able to begin reporting the required information with respect to 2020 and 2021 data by Dec. 27, 2022,” the guidance said.

The guidance comes as the price transparency rule was challenged in court in separate lawsuits from the U.S. Chamber of Commerce and the Pharmaceutical Care Management Association (PCMA), which represents pharmacy benefit managers.

PCMA charges in its lawsuit that the rule would confuse consumers and create a costly endeavor for insurers and PBMs. The chamber argues that the requirements could also raise costs to consumers by requiring insurers to reveal confidential and commercially sensitive information to competitors.

Here Are 3 Major Policy Areas That Health Industry Groups Are Closely Watching In $3.5T Infrastructure Bill

Here are 3 major policy areas that health industry groups are closely  watching in $3.5T infrastructure bill | FierceHealthcare

Source: Fierce Healthcare, by Robert King

The Senate is getting into the nitty-gritty of what exactly will be included in a massive $3.5 trillion infrastructure package that seeks to make major reforms to Medicare.

And that means healthcare industry groups are watching very closely.

Democrats have called for the $3.5 trillion package to tackle drug prices and add dental, hearing and vision benefits to Medicare, as well as efforts to expand coverage. But the actual legislation on how to do that will now be crafted by Senate committees and considered by lawmakers when they return from their August recess next month.

Democrats aim to use a procedural pathway called reconciliation that lets budget bills pass the Senate via a simple majority and avoid a legislative filibuster. The Senate took its first step toward creating the package when it approved a budget resolution earlier this week.

Here are some of the major issues several payer and provider groups are keeping an eye on and what they want to include in the final package.

Expanding healthcare coverage

Several provisions in the $3.5 trillion package aim to expand health insurance coverage, but how that can happen is still going to be hammered out.

Payers and provider groups were in favor of making permanent enhanced income-based subsidies for Affordable Care Act (ACA) exchange coverage. The American Rescue Plan Act boosted subsidies but only for the 2021 and 2022 coverage years.

But the ACA enhancements aren’t the only coverage expansions that Congress is mulling.

The framework for the $3.5 trillion package calls for legislation to close the Medicaid coverage gap, which refers to low-income residents that don’t qualify for ACA income-based subsidies but reside in states that didn’t expand Medicaid under the ACA.

Some groups were surprised the issue has gotten so much traction in Congress over the past several months.

“The momentum for that has been pretty impressive,” said Dan Jones, vice president of federal affairs for the Alliance of Community Health Plans (ACHP), which represents nonprofit health plans.

But now committees will decide how the coverage gap gets filled, and some groups are pushing for a quick solution to the issue.

Several Senate Democrats introduced legislation last month that would create a new program resembling Medicaid through which residents in states that didn’t expand the program can get coverage. However, such a program could take a while to set up, said Chip Kahn, president and CEO of the Federation of American Hospitals (FAH).

Kahn instead endorsed a stopgap that would make people in the coverage gap eligible for subsidies on the ACA’s exchanges.

“If we make these people eligible, they would be fully subsidized and have good coverage,” he told Fierce Healthcare.

The additional subsidies could run for a few years and give more states time to expand Medicaid under the ACA, Kahn said. The American Rescue Plan Act did increase the federal matching rate for Medicaid for newly expanded states, but the sweetener hasn’t enticed more states.

“The great opposition to ACA is blowing over to an extent,” he said. “We will have to wait and see how it plays out, but we could find other ways to get those other states to move.”

Finally tackling drug prices, but how?

Senate Democrats signaled that they want to address drug prices in the infrastructure bill, but to what degree remains uncertain.

Progressive lawmakers want to give Medicare broad authority to negotiate for lower drug prices, a desire shared by President Joe Biden. Implementing price negotiation authority could also produce savings that could help pay for the package. But more moderate members could balk at broad negotiation authority.

Some groups see an opportunity to get more bipartisan proposals to be included into the bill.

The advocacy group Campaign for Sustainable Rx Pricing is pushing lawmakers to adopt a series of bipartisan reforms that include capping out-of-pocket drug costs for seniors. The campaign is a coalition of hospital, pharmacy, payer and other provider groups as well as advocacy groups such as AARP.

“We called for action on solutions that have garnered bipartisan support in the past,” said spokesman Jon Conradi in an interview with Fierce Healthcare.

Another potential issue is forcing drugmakers to pay a larger share of coverage in the catastrophic phase in Medicare Part D. Drugmakers now cover 50% of the costs of their products when a beneficiary reaches the catastrophic phase, which is the maximum out-of-pocket limit beneficiaries pay for drugs.

“Now is the time for action,” Conradi said. “There is truly unprecedented momentum for Congress to act on prescription drug prices.”

Ditching the rebate rule for good

Drug price negotiations isn’t the only item Congress has identified as a potential pay-for to help cover the costs of the package.

Several payer groups are hoping Congress also decides to fully repeal a controversial Trump-era rule that eliminates safe harbor protections for Medicare Part D drug rebates and creates a new safe harbor for discounts at the point of sale.

The bipartisan infrastructure package that passed the Senate recently includes a three-year delay in implementing the rule until 2026. The delay netted roughly $50 billion in savings for the package.

Now, payers are hoping to put the final nail in the coffin.

Conradi said the campaign wants the rule to be fully repealed because it can “increase overall drug costs.”

The Pharmaceutical Care Management Association, which represents pharmacy benefit managers, called for a permanent repeal.

“We are encouraged that there is bipartisan support for repealing the Medicare rebate rule, which if allowed to take effect will drastically increase premiums for seniors and other Medicare Part D beneficiaries,” said President and CEO JC Scott in a statement after passage of the bipartisan infrastructure package.

Payer and provider groups are also keeping a watchful eye on any other pay-fors that could be employed as committees start drafting the legislation.

“Any changes to the Medicare Advantage program are things we are paying close attention to,” said Jones of ACHP. “Those are always things that we want to keep a close eye on.”

FAH was disappointed that the bipartisan infrastructure package restarted a 2% sequester cut to Medicare payments next year as a pay-for.

“I don’t anticipate on the hospital front any major changes on the payment side of this bill,” Kahn said. “Until the fat lady sings, you need be wary.”

Framework For $3.5T Senate Package Seeks To Close Medicaid Gap, Add New Medicare Benefits And Tackle Drug Prices

Framework for $3.5T Senate package seeks to close Medicaid gap, add new  Medicare benefits and tackle drug prices | FierceHealthcare

Source: Fierce Healthcare, by Robert King

Senate Democrats want to give Medicare the power to negotiate for lower drug prices, add new benefits to Medicare and close a Medicaid coverage gap in a new $3.5 trillion infrastructure package.

Democrats unveiled on Monday their budget resolution for the package, the first step to passing the legislation in the Senate.

The budget resolution, set to be considered in the chamber this week, outlines ambitious and long-held Democratic healthcare policies that the final legislation is likely to include.

The policies included in the resolution include:

  • * Adding dental, hearing and vision benefits to Medicare.
  • * Giving Medicare the power to negotiate lower drug prices. Sen. Bernie Sanders, I-Vt., a leading negotiator on the package, tweeted Monday that the savings from drug price negotiations will help pay for other parts of the package such as adding the new benefits to Medicare.
  • * Creating a new federal program to cover Americans who would be eligible for Medicaid if their state had expanded the program under the Affordable Care Act. Several senators have proposed legislation to create a separate, Medicaid-like program to cover these residents.
  • * Making new investments in home and community-based services to “help seniors, persons with disabilities and home care workers,” the resolution said. A roughly $1 trillion bipartisan infrastructure package originally included investments for home care, but that money didn’t make it into the final package to be considered this week.
  • * Extending a boost to ACA income-based subsidies that were included in the American Rescue Plan Act. The boosted subsidies are set to expire after the 2022 coverage year.

Democrats in the House and Senate aim to pass the $3.5 trillion package via reconciliation, a procedural move that allows budget bills to move through the Senate via a simple majority and avoid a legislative filibuster.

Each committee will craft and pass its own part of the package and then the Senate will bundle them together for final passage, which is likely to occur after the nearly monthlong August recess.

The Senate is expected to pass this week a roughly $1 trillion bipartisan infrastructure package that would delay until 2026 a controversial Part D rebate rule and restart Medicare sequester cuts that were on pause during the pandemic.

House Speaker Nancy Pelosi has said that she wants to pass the bipartisan infrastructure package and the $3.5 trillion legislation at the same time.

The hospital advocacy group Federation of American Hospitals praised most of the health proposals, including making the enhanced ACA subsidies permanent and closing the Medicaid gap.

FAH President Chip Kahn said in a statement that the best way to close the Medicaid gap is to build on the ACA and not to create a separate program, as legislation endorsed by several Democrats aims to do.

Kahn also cautioned Democrats against raising the corporate tax rate to help pay for the package.

“Raising the corporate tax rate is the wrong prescription at the wrong time,” he said. “It punishes the very domestic companies still recovering from the ongoing pandemic, and which we count on to grow the economy and create jobs.”

3 Key Health Policies In The Senate’s $1T Infrastructure Package


Source: Fierce Healthcare, by Robert King

The Senate is poised to pass a roughly $1 trillion bipartisan infrastructure package that will delay until 2026 a controversial Part D rebate rule.

While most of the new funding in the package, the text for which was released Sunday, goes toward infrastructure projects such as new roads or information technology, there are several healthcare-related provisions that could impact the industry.

Here are some of the healthcare items included:

Resuming Medicare sequester cuts

Providers got a win in the package when lawmakers agreed to not raid unallocated COVID-19 Provider Relief Fund monies. However, the legislation does deal a blow to the industry’s efforts to halt a 2% cut to Medicare payments from resuming.

The cuts were created under sequestration in 2013. Congress decided to pause the cuts last year at the onset of the pandemic to help providers struggling financially. The moratorium on the cuts though ends after this year.

Major provider groups have implored Congress to not resume the cuts to help pay for infrastructure. The American Hospital Association wrote to congressional leaders last month saying that “providers cannot sustain additional cuts to the Medicare program;”

Requiring drugmakers to refund Medicare for any discarded drugs

The requirement applies to drugs dispensed under Medicare Part B, which reimburses for drugs administered in a doctor’s office such as chemotherapy. The requirement applies to single-dose containers or single-use package drugs.

Each quarter starting in 2023 the manufacturer must provide a refund for any single-use or single-dose products that were discarded that period; and

Requiring more domestic production of equipment

The pandemic exposed debilitating gaps in the supply chain for medical goods that include personal protective equipment. Manufacturing of PPE was based primarily overseas and companies experienced long delays right as demand accelerated with the onset of the pandemic.

The legislation demands that any federal contract to buy PPE must be for two years and go to a domestic manufacturer. The two-year time frame will give the domestic PPE maker enough financial security to stay in the market.

The Senate is expected to vote this week on the package. It will then consider a $3.5 trillion package that could clear the chamber via a procedural move called reconciliation that ensures budget bills can pass via a simple majority and bypass the 60 votes needed to break a filibuster.

Democrats have sought to add more healthcare related provisions in the $3.5 trillion package, including adding dental, vision and hearing benefits to Medicare.

Sen. Ron Wyden, D-Oregon, told Fierce Healthcare last week that he is working to add drug pricing provisions into the package, including giving Medicare the authority to negotiate for lower prices.

430 Groups Demand Congressional Action On Permanently Expanding Telehealth Flexibilities

US capitol building

Source: Fierce Healthcare, by Robert King

More than 400 advocacy groups are calling for Congress to act quickly to permanently expand flexibilities for telehealth that could go away after the end of the COVID-19 public health emergency expected to run through 2021.

The 430 groups sent a letter to congressional leadership on Monday underscoring the urgency for action now amid concerns from providers that expanded telehealth access could expire abruptly after the emergency ends.

“Once it expires all bets are off,” Jen Covich Bordenick, CEO of the eHealth Initiative, told Fierce Healthcare in an interview. The initiative is one of the 430 groups that signed onto the letter.

At the onset of the pandemic, the Department of Health and Human Services removed several barriers to telehealth reimbursement under Medicare. The move helped fuel a massive explosion in telehealth use among providers as patients were afraid to get care for fear of contracting COVID-19.

Some of the initial barriers that were lifted include a requirement for an in-person visit from the patient before going through telehealth.

Other restrictions included a requirement that a provider be in the same geographic area as the patient.

“We want patients to access care wherever they are,” Covich said.

Lawmakers in both the House and Senate have introduced legislation to remove barriers such as the originating site requirement.

But it remains unclear when Congress could act on the issue, such as whether the fix is included in a major infrastructure push being negotiated now or during an end-of-year spending package.

Currently, the Senate is considering a roughly $1 trillion bipartisan infrastructure package and a $3.5 trillion package intended to pass via reconciliation, a procedural move that ensures budget bills can bypass a filibuster and pass via a simple majority.

“It is a fully bipartisan issue,” said Krista Drobac, executive director of the Alliance for Connected Care, another group signed onto the letter. “That alone should bring it to the top of the agenda for Congress.”

Other groups who signed onto the letter include the American Medical Association, American College of Physicians and the Health Information and Management Systems Society.

Advocates also hope that any legislation approved by Congress gives regulatory flexibility to HHS and Centers for Medicare & Medicaid Services.

The agencies, for example, should determine which types of providers should get reimbursement from Medicare for telehealth services.

“Rather than have that in the legislation, we want CMS to make those decisions in regulation rather than having to go back to Congress to make changes,” Covich said.

CMS Proposes Extension Of Medicare Telehealth Coverage

Medicare and Telehealth: Coverage and Use During the COVID-19 Pandemic and  Options for the Future | KFF

Source: Healthcare Dive, by Shannon Muchmore

CMS is proposing to extend Medicare coverage of certain telehealth services granted for the COVID-19 public health emergency to the end of 2023 to help gather data that can determine whether the services should be permanently covered.

The agency similarly suggested allowing for some mental healthcare to be provided on an audio-only basis going forward in the proposed Physician Fee Schedule for 2022, released Tuesday. The annual rulemaking also includes changes to the Quality Payment Program and seeks feedback on how to improve data gathering from providers in an effort to better health equity.

“Over the past year, the public health emergency has highlighted the disparities in the U.S. health care system, while at the same time demonstrating the positive impact of innovative policies to reduce these disparities,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “CMS aims to take the lessons learned during this time and move forward toward a system where no patient is left out and everyone has access to comprehensive quality health services.”

But provider groups were not happy with the payment adjustment included — a 3.75% reduction to the conversion factor, due to budget neutrality requirements. The Medical Group Management Association, which represents physician practices, said in a statement that it would seek congressional intervention to avoid the cut.

Industry lobbies were pleased, however, the proposed rule delays enforcement of the Appropriate Use Criteria program, which requires providers to use clinical decision support mechanisms when ordering certain advanced diagnostic imaging.

The requirement was set to go into effect in January but has now been extended for a year. The American Hospital Association said the change, “will enable hospitals and other providers to maintain their ongoing response to the COVID-19 crisis while allowing essential education and operations testing of the AUC program to occur.”

Groups representing accountable care organizations, meanwhile, applauded another delay, wherein CMS proposed waiting on a transition in the Medicare Shared Savings Program to electronic quality measure reporting.

The agency said in a fact sheet on the PFS that the temporary extension of Medicare telehealth coverage is meant to serve as a “glide path to evaluate whether the services should be permanently added to the telehealth list following the COVID-19 PHE.”

Lawmakers, patient advocates and many industry groups have said they support permanently adding many of the services to the coverage list, but CMS said it wants more information on their efficacy. The agency declined some proposals for permanent coverage as not meeting the criteria on the books.

“We view the draft rule as a modest positive for telehealth stakeholders; however, we continue to believe bigger impact changes will require additional legislation,” Cowen analysts wrote in a Tuesday note on the rule.

Telehealth use has declined as people have received vaccinations and felt more comfortable going into a doctors office, but visit rates are still much higher than before the pandemic. Most stakeholders expect that to hold.

The rule would put into effect a law that removes geographic restrictions for diagnosis, evaluation or treatment of a mental health disorder and allows a patient’s home to serve as an originating site for a telehealth visit. It places some restrictions, however, including a requirement that the patient had an in-person visit some time within six months before the virtual visit.

Patient advocates and some providers may see this as too restrictive, citing the potential loss of access to care.

The proposed overhaul of the QPP includes the introduction of Merit-based Incentive Payment System Value Pathways for the 2023 MIPS performance year and the end of traditional MIPS at the end of the 2027 performance year.

Also, subgroup reporting would be allowed in an effort to provide “more comprehensive and granular” data sets. And clinical social workers and certified nurse-midwives would be added to the list of clinicians eligible for the program.

The initial set of MVP clinical areas would be: rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine and anesthesia.

CMS said the changes should allow clinicians to see “greater returns on their investment in the program as we see higher payment adjustments as well as begin to see a more equitable distribution within our scoring system and small practices no longer bearing the greatest share of the negative payment adjustments.”

For health equity data collection, CMS could give providers confidential reports with data points including race, disability, rural populations and LGBT status. This information would support initiatives to close equity gaps and allow providers to identify disparities, the agency said.

Plugging Obamacare’s Biggest Hole Poses Dilemma For Democrats

Plugging Obamacare's biggest hole poses dilemma for Democrats - POLITICO

Source: Politico, by Rachel Roubein and Alice Miranda Ollstein

Democratic lawmakers are grappling with how to extend health insurance to millions of poor Americans in states that have refused Obamacare’s Medicaid expansion, believing their upcoming party-line “human infrastructure” package represents the best chance to plug the health law’s biggest gap.

After months of behind-the-scenes discussions, Democrats are coalescing around three options for closing the coverage gap in the Medicaid expansion holdout states, according to nine sources on and off the Hill. These approaches, which would leverage the existing Obamacare insurance marketplaces or require the Biden administration to create a new coverage program, each carry risks. And lawmakers still don’t see a clear path forward as they face a narrowing window to assemble a massive package of Democratic priorities.

“The question has always been how to do it. It’s a pretty challenging question,” said House Ways and Means Chair Richard Neal (D-Mass.), whose tax-writing panel is helping craft a fix.

Tackling the Medicaid gap would fulfill President Joe Biden’s pledge to extend coverage to the 2.2 million low-income adults in the 12 states where Republican officials have resisted the program for nearly a decade. It would also give Democratic lawmakers from those holdout states — like Raphael Warnock of Georgia, who’s leading efforts in the Senate to close the Medicaid gap — an achievement to campaign on, with control of both chambers up for grabs in next year’s midterms and health care remaining an important issue for voters.

The costly effort faces competition from other Democratic health care priorities that are jostling for position in infrastructure legislation, including an expansion of Medicare’s benefits and permanently increasing financial aid to people who purchase coverage on the ACA’s health insurance marketplaces.

The debate over how best to spend limited health care dollars could force Democrats to choose between leveraging their control of Washington to shore up the ACA, or making a play for swing voters by adding coverage of dental, vision and hearing to Medicare. Closing the Medicaid coverage gap polls high with Democratic supporters, though independents and Republicans in a recent Kaiser Family Foundation poll said expanding Medicare benefits is a bigger priority.

“I’m very keenly aware that poor people are the first to get squeezed out when there’s a budget problem,” said Rep. Lloyd Doggett (D-Texas), whose home state has the nation’s highest uninsured rate. “I’m really pushing to say: At least do something for people who’ve been left out for more than a decade and have nothing to show for the Affordable Care Act. But it’s a challenging sell.”

Yet, momentum for plugging the coverage gap has grown in recent weeks, after key Democratic leaders have embraced the effort. Congressional staff are still hashing out thorny policy questions over how to expand coverage to poor adults in the Medicaid expansion holdout states, but no clear preferred policy has emerged amid concerns over potential drawbacks. Some approaches could take years to set up, cost more than leaders want to spend or inadvertently penalize states that already expanded Medicaid.

Advocates and Democratic lawmakers from Medicaid expansion holdout states say this month marks the first critical deadline in the effort, as congressional budget writers seek to finalize the parameters for infrastructure legislation the party can pass through reconciliation without Republican votes. While that budget resolution won’t include the details of which health policies make the final cut, it could provide the first sign of whether lawmakers are working with enough money to fund a Medicaid gap fix.

The House is largely leading efforts to craft the policy, sources said. Options under consideration include:

— Allowing low-income adults to get free private coverage through Obamacare’s insurance marketplaces. Financial assistance for the marketplaces has been closed off to people earning below the poverty line, about $13,000 for an individual, because Obamacare’s drafters expected they would be covered by Medicaid expansion. However, a 2012 Supreme Court decision made the expansion optional for states, creating the coverage gap Democrats are trying to close.

— Directing the Department of Health and Human Services to stand up a new Medicaid-like program for people who would otherwise be covered by Medicaid expansion in the holdout states. Warnock, whose election helped secure Democratic control of the Senate and faces voters again next year, plans to introduce legislation as soon as next week that would back this approach and substantially boost financial incentives for holdout states to expand Medicaid, according to a draft bill obtained by POLITICO.

— A hybrid model that could address concerns about either of the two approaches, according to a senior Democratic aide. People could quickly receive free coverage on the marketplaces until federal officials can create a new program that would likely provide better benefits.

A White House spokesperson didn’t comment on whether Biden is pushing lawmakers to address Medicaid expansion in the human infrastructure package, which is expected to also include investments in child care, education and combating climate change. The spokesperson referred POLITICO to a recent tweet from domestic policy chief Susan Rice that said Biden “is ready to work with Congress this year to close the coverage gap.”

Biden’s budget called for creating a federal-run health insurance option to cover people in the Medicaid expansion gap, but the White House hasn’t publicly weighed in on the approaches Congress is considering. Policymakers see complications with each idea.

For instance, relying on the Obamacare markets could give the new enrollees skimpier benefits than what they would receive through Medicaid. It could also require the government to provide costly subsidies to private insurers to cover out-of-pocket health costs that Medicaid would typically cover. But creating a new federal program would take time to set up.

Those drafting the legislation are trying to ensure they don’t inadvertently reward states that refused expansion or incentivize expansion states to drop coverage so that the federal government will foot the entire bill.

“To the extent you give more incentives and benefits to irresponsible states, then some of the responsible states will say: ‘I want that, too,’ which adds to the cost,” Doggett said. “How do you justify excluding states from a federal Medicaid program?”

Matthew Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy whose research focuses on the Medicaid coverage gap, and other experts said they’re not concerned about states dropping Medicaid expansion, given that the federal government picks up 90 percent of the cost. Still, Medicaid experts believe policymakers must provide the right balance of “carrots and sticks” to discourage states from dropping out.

Whatever approach lawmakers choose will have to pass muster with the Senate parliamentarian, who interprets whether policies satisfy strict reconciliation rules. However, lawmakers and outside experts are optimistic any policy would survive because changes to the Obamacare markets and Medicaid expansion have previously been pushed through the fast-track budget process.

The effort recently received a major boost from the powerful Congressional Black Caucus, Congressional Hispanic Caucus and the Congressional Asian Pacific American Caucus — as well as House Majority Whip Jim Clyburn. The groups argue that closing the coverage gap would be “one of the single most important steps” toward reducing the stark racial inequities in America’s health care system.

It would also give red state Democrats a concrete win to take to their voters.

“By this time next year, by the time you guys run for re-election next year, you’ll be able to run on Medicaid expansion,” Clyburn recently told lawmakers in Alabama’s statehouse. “I think we [can] get that done — I know I’m gonna raise hell to get it done.”

Last Updated 09/22/2021

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