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Last Build Date: Mon, 24 Jul 2017 21:00:23 +0000


House Appropriations Committee Approves Draft Bill Affecting ACA Funding For 2018

Mon, 24 Jul 2017 20:23:40 +0000


On July 18, 2017, the House Appropriations Committee approved a draft Labor, Health and Human Services, Education, and Related Agencies Appropriations bill for 2018 (Committee Report). The bill includes a number of provisions relevant to the Affordable Care Act. It would:

  • Require the Department of Health and Human Services (HHS) to establish a website providing detailed information as to grants provided through the Prevention and Public Health Fund;
  • Require HHS to provide information on all full-time equivalent employees and contractors who have been engaged in implementing the ACA since its enactment, subject to certain exceptions;
  • Require HHS to provide information regarding expenditures for the exchanges since the enactment of the ACA, as well as enrollment information for the exchanges;
  • Prohibit the use of funds from the Medicare trust funds or the Centers for Medicare and Medicaid Services’ program management account for funding risk corridor obligations;
  • Provide a report on how the ACA’s preventive services requirement will impact eligibility for discretionary HHS programs;
  • Transfer funds appropriated under the Prevention and Public Health Fund to other specified purposes as identified in the committee report;
  • Prohibit the use of Prevention and Public Health Funds for lobbying;
  • Prohibit user fees to fund the exchanges;
  • Prohibit funding for the navigator program;
  • Prohibit funding for implementing the ACA, except for certain provisions pertaining to Medicare rate-setting and the Medicaid drug discount program;
  • Rescind $15 million in funding for the Independent Payment Advisory Board; and,
  • Rescind $323 million that apparently still remains from the preexisting condition high-risk pool.

To become law, the appropriations proposed bill would have to be enacted by the whole House and then be approved by the Senate, or be reconciled with Senate appropriations language. An appropriations bill in the Senate is subject to a filibuster. It is very unlikely, therefore, that all of the House provisions will appear in final legislation. It is much more likely that the government will continue to function under a continuing resolution.

The IRS has posted tax year 2017 schema and business rule packages for employers and insurers filing forms 1094-B, 1094-C, 1095-B, and 1095-C. The pages are quite similar to those used in 2016. Neither the House’s American Health Care Act nor the Senate’s Better Care Reconciliation Act repeals the ACA’s employer and individual responsibility mandate reporting requirements, so these forms are likely to be around for some time.

Senate Health Care Legislation Would Grant HHS Unprecedented Power Over States

Mon, 24 Jul 2017 18:07:25 +0000

In an earlier Health Affairs Blog post, we described several provisions in the Senate’s Better Care Reconciliation Act (BCRA) that would grant the U.S. Department of Health and Human Services (HHS) largely unchecked authority to make decisions that could significantly affect state budgets. We noted that, based on past interactions between state and federal Medicaid officials, HHS might use its resulting leverage to pressure states to fall in line with the current Administration’s policy preferences. Perhaps inevitably, exceptionally broad delegation of policymaking authority has become a defining feature of the Senate Majority Leader’s quest to restructure one-sixth of the American economy without hearings, expert testimony, committee consideration, or other safeguards of regular order. The President famously observed that health issues are “incredibly complicated.” Resolving such issues with careful attention to detail is too high a bar for most legislators to clear while moving at breakneck speed. For Republican leaders in Congress, the almost inescapable solution has been to structure legislation so that HHS will eventually answer policy questions that Congress currently lacks the time to resolve. Wholesale delegations of lawmaking power to Executive-branch agencies will almost certainly be larded throughout proposed legislation if the Senate approves this week’s expected “motion to proceed,” which would allow passage of a final bill after just 20 hours of debate on the Senate floor. Extraordinary powers granted to HHS Our earlier analysis explained how BCRA gives HHS substantial, unchecked authority to revise the initial setting of Medicaid per capita caps, to change state cap amounts in future years, and to deny Medicaid funding for public health emergencies if HHS decides that such funding would not be “appropriate.” The latest version of the bill similarly creates major new grant programs with almost no ground rules for dividing money among states. Instead, BCRA gives HHS largely unchecked power to decide who receives the money appropriated by Congress: $132 billion in market stabilization grants, which states can spend on insurers, consumers, or providers (including public hospitals). These funds can be distributed using any “allotment methodology” desired by HHS, as long as Alaska gets $1 billion a year. The bill says not one word about how to distribute $44.8 billion in grants that “support substance use disorder treatment and recovery support services,” leaving HHS with essentially unlimited authority. An equally striking example involves Medicaid block grants. After listing specific provisions of the Medicaid Act that would not apply to states choosing the block-grant option, BCRA adds that “any other provision” of the Medicaid statute “that the Secretary deems appropriate, shall not apply.” To a remarkable degree, defining the permitted range of state policy options would be left in HHS’ hands, without Congressional specification. For example, the HHS Secretary could rewrite Medicaid law to systematically favor non-expansion states over those that have expanded the program, taking such steps as curtailing or barring federal funding for state Medicaid administration costs to serve the expansion population. In the past, Republican lawmakers, including then-Congressman Tom Price (R-GA), vociferously criticized the Affordable Care Act’s (ACA) grants of broad discretion to HHS — especially the ACA’s authorization for a newly created Center for Medicare and Medicaid Innovation (Innovation Center) to test and then expand new methods for financing and delivering health care. While the Innovation Center has considerable flexibility, the ACA imposed constraints far more limiting than the BCRA provisions discussed here. For example, the ACA identifies 12 models from which the Innovation Center must choose in authorizing demonstrations; lists eight criteria (e.g., procedures to monitor patient care to meet the needs and preferences of affected[...]

Introducing A New Series Of Health Affairs Policy Primers: Prescription Drug Pricing

Mon, 24 Jul 2017 15:16:24 +0000


For policy makers at every level of government it is easy to recognize the deep impact of soaring prescription drug prices. Bold headlines, countless hearings, and recent legislation have all raised the alarm about, and floated policy solutions to address, sharp price spikes, sudden shortages, growing out-of-pocket costs, and other serious obstacles to patients’ access.

Much more difficult is the work required to untangle the complicated interplay of forces that are driving prices so high. Health Affairs has long published the work of researchers doing the critical work of identifying, evaluating, and measuring those forces. But just as important is translating that research and providing actionable evidence for an audience beyond academia, particularly for those making policy in both the public and private spheres.

It is with that goal in mind that Health Affairs has embarked on a new project. Today, we are releasing the first four in a series of twelve primers on key issues currently shaping the prescription drug market. Each primer offers a short, accessible overview of the issue and a close examination of how it affects pricing.

These primers are the result of a collaborative effort aimed at providing policy makers the tools they need to approach these issues thoughtfully and deliberately, armed with concrete evidence and the latest research. This spring Health Affairs convened an expert advisory board to help identify and narrow the list of topics on which the primers would focus. We are grateful for the board’s guidance:

  • Aaron Kesselheim, Brigham and Women’s Hospital and Harvard Medical School
  • Steve Pearson, The Institute for Clinical and Economic Review
  • James Robinson, UC Berkley School of Public Health
  • Stacie Dusetzina, UNC Eshelman School of Pharmacy; and,
  • Gail Wilensky, Project HOPE

The primers, drafted in collaboration with Prevision Policy LLC, underwent an independent peer-review and revision process conducted by Health Affairs led by consulting editor Laura Tollen. This project was made possible by generous support from The Commonwealth Fund and Memorial Sloan Kettering Cancer Center’s Drug Pricing Lab.

The four briefs released today explore key forces that come into play early along the winding the path from drug development to the pharmacy counter: Expedited Approval Pathways; Pricing Orphan Drugs; Biosimilars; and Patent Settlements. Later this summer and early fall, we will move further along that path, releasing two more sets of primers, plus a series of three white papers laying out potential policy solutions to the challenge of surging prescription drug prices.

Our hope is that these primers will provide a quick, clear, easy-to-use, and impartial foundation for anyone seeking to understand what’s behind the rising price of prescription drugs.

Medicaid Expansion Reduced Unpaid Medical Debt And Increased Financial Satisfaction

Mon, 24 Jul 2017 13:49:57 +0000

As federal lawmakers continue to debate whether to repeal, and perhaps eventually replace, the Affordable Care Act (ACA), it is clear that Republican health care proposals would significantly scale back a key feature of the ACA: allowing states to expand Medicaid for adults up to 138 percent of the federal poverty line. This policy decision should be informed by a thorough accounting of the ACA’s Medicaid expansion’s effects. In this post, we present new evidence that the ACA’s Medicaid expansion reduced the share of low-income Americans with unpaid medical debt and improved their satisfaction with their own financial situation. This evidence is important not only for federal lawmakers debating whether to repeal the ACA, but also for state policymakers in non-expansion states who, if the ACA is retained, will have to decide whether to change course and expand Medicaid. What Is Known About The ACA Medicaid Expansion’s Effects To date, several studies compare the experiences of low-income adults in states that chose to expand Medicaid under the ACA with their counterparts in states that declined to expand Medicaid. These studies find that the Medicaid expansion reduced uninsurance for adults with low incomes. The expansion led to increased access to care, and there is some evidence that it improved measures of self-assessed health. These studies indicate that the ACA’s Medicaid expansions have delivered significant benefits to the low-income Americans who live in states that chose to expand Medicaid. However, they do not address a key question about the effects of the Medicaid expansion: how it affects families’ finances. Medicaid And Financial Protection Insurance is most fundamentally about giving people financial protection from the risk of needing costly health care that could otherwise overwhelm their personal finances. The landmark Oregon Medicaid experiment that took place before the ACA was enacted found that gaining Medicaid led to large reductions in catastrophic out-of-pocket medical expenditures and improvements in other financial outcomes. However, we know little about the effect of the ACA’s Medicaid expansions on financial outcomes, in part because data on financial outcomes are less accessible for researchers than publicly available data on health insurance and access to care. A suggestive bit of evidence is that the national rate of personal bankruptcies, which can be driven by medical debt, have fallen since the passage of the ACA. On the other hand, current FDA Commissioner Scott Gottlieb (formerly of the American Enterprise Institute) and others argue, based on observations about health care firms’ write-offs of unpaid debt, that the ACA may be increasing unpaid medical debt. Two recent studies of the ACA Medicaid expansion’s effect on financial wellbeing use credit report data and find that low-income areas in Medicaid expansion states had significant reductions in unpaid non-medical bills and in the amount of non-medical debt sent to third-party collection agencies, compared to low-income areas in states that did not expand Medicaid. One other study finds that low-income adults in Medicaid expansion states had reductions in problems with, and worries about, paying medical bills. Measuring the Effects of the Medicaid Expansion on Financial Outcomes To generate new insight into how the ACA’s Medicaid expansion affected financial outcomes, we examined data from an untapped source, the National Financial Capability Study (NFCS). The NFCS was designed to measure different dimensions of financial capabilities among Americans and track these changes over time. The study was developed collaboratively between the U.S. Department of Treasury and the FINRA Investor Education Foundation. Over 25,000 people completed the survey online in each wave, and participants come from all 50 states and Washington, D.C. Details about NFCS’s survey methodology are here. We use data from 2012 and 2015, which correspond to th[...]

Senate Parliamentarian Rules Several BCRA Provisions Violate The Byrd Rule

Fri, 21 Jul 2017 23:17:23 +0000

Democrats are reporting that on July 21, 2017, the Senate Parliamentarian ruled that a number of provisions of the Republican Better Care Reconciliation Act (BCRA) violate the Byrd Rule, and thus cannot be passed by the Senate using the reconciliation act procedure through which Congress has been trying to repeal the Affordable Care Act (ACA). The Byrd Rule requires, among other things, that a provision adopted through a reconciliation act affect the revenues or outlays of the United States in a manner than it not merely incidental to another purpose. A provision that the Parliamentarian rules to be impermissible under the Byrd rule is subject to a point of order, which can only be overruled, according to tradition, by a 60-vote majority. The provisions that the Parliamentarian ruled may be stricken if raised by a point of order include: The provision defunding Planned Parenthood; The provisions prohibiting the use of small business tax credits and individual market premium tax credits to pay for health plans that cover abortions; The sunset of an essential health benefit coverage requirement for Medicaid plans; The section funding cost-sharing reductions (CSRs), which the Parliamentarian ruled was redundant of current law, which already funds them (this ruling seems contrary to the lower court’s ruling in House v. Price that money had not been appropriated for the CSRs, but is consistent with the belief that the CSRs are already built into the budget baseline, thus an appropriation does not affect the deficit. A bill to clarify the appropriation situation could, of course, be passed separately from the reconciliation act; The six-month waiting period for individuals who have not maintained continuous coverage; The provision sunsetting the federal medical loss ratio requirement and allowing states to set the medical loss ratio; A provision, that has been removed from the most recent version of the BCRA, that might have allowed states to rollover unused Medicaid block grant funds and possibly use them for other purposes; The “Buffalo Bailout” which would have limited the ability of New York State to require counties other than those in New York City to contribute funding to the state’s Medicaid program (the ruling on this provision should caution against including further state-specific provisions in future versions of the legislation); A provision grandfathering certain Medicaid waivers and prioritizing Medicaid Home and Communit-Based Services Waivers; A provision requiring a report by the Department of Health and Human Services (HHS) to Congress regarding the preferability of adopting a different system for reporting Medicaid data; and, A section requiring HHS to consult with the states before finalizing Medicaid rules. The Parliamentarian upheld against a Byrd rule challenge, A provision allowing state the option of imposing work requirement on Medicaid enrollees who are not disabled, elderly, pregnant, or within 60 days of giving birth; A provision granting $10 billion to Medicaid non-expansion states; The state stability and innovation fund, which imposes abortion restrictions by funding the program through the Children’s Health Insurance Program, which already prohibits abortion funding; A provision adjusting per capita cap targets for low-spending and high-spending states to promote equity; The permanent repeal of the cost-sharing reduction program beginning in 2020; and, A provision requiring states to include information on per capita enrollment and expenditures, psychiatric hospital expenditures, and children with complex conditions in their Medicaid expenditure reports. The Parliamentarian is still reviewing: The provision expanding section 1332 to remove the current guardrails on state innovation waivers; The provisions allowing small business association health plans that would be regulated as large group health plans, largely free from state regulation; The provision allowing age rati[...]

CBO’s Estimates Of The Revised Senate Health Bill

Fri, 21 Jul 2017 22:44:22 +0000

The Congressional Budget Office (CBO) produced cost estimates for two of the three versions of the Better Care Reconciliation Act (BCRA), sponsored by Senate Republican leaders. A comparison of the June 26 and July 20 estimates confirms that the two BCRA versions do not differ substantially from each other. CBO has not estimated the impact of the much-discussed amendment to the BCRA sponsored by Senator Ted Cruz (R-TX), which is included in the July 13 draft. That provision would allow insurers to sell products to consumers that are out of compliance with the requirements of the Affordale Care Act (ACA), as long as they also offer at least one ACA-compliant product at each metal level. The July 20 version of the BCRA incorporates several major policy changes from the June version, including: The new taxes on high-income families imposed by the Affordable Care Act (ACA) would be retained. Those taxes, the Medicare payroll tax of 0.9 percent on the wages of high earners and the 3.8 percent tax on the non-wage incomes of the same households, would have been repealed by the earlier version of the BCRA. An additional $70 billion would be added to the State Stability and Innovation Fund. Funds from Health Savings Accounts (HSAs) could be used to pay the premiums of high-deductible health insurance plans purchased on the non-group market. A new $45 billion fund would be established to support state efforts in combatting the opioid epidemic. This fund does not figure prominently in CBO’s estimates of the coverage and premium effects of the legislation. CBO’s assessment of the most recent BCRA draft includes the following key findings: The legislation would reduce federal spending by $903 billion over ten years and reduce federal revenues by $483 billion over the same period. The net deficit reduction over the coming decade would be $420 billion. CBO estimated that the June version of the BCRA would have reduced federal revenue by $701 billion over ten years, or $218 billion more than the tax cuts in the current version of the legislation. CBO estimates that the revised BCRA would increase the number of people going without health insurance by 15 million in 2018 and 22 million in 2026. These estimates are essentially unchanged from CBO’s previous estimate. The largest spending reduction in the revised BCRA is in the Medicaid program. CBO estimates the bill would reduce Medicaid spending by $756 billion over ten years, of which $575 billion comes from pulling back on the enhanced federal matching rate for the ACA’s expansion of the program. The proposal to impose per-person limits on future federal expenditures for the program accounts for most of the remaining savings. CBO expects Medicaid enrollment to decline by 10 million people in 2021 and 15 million in 2026. CBO expects that terminating the penalties associated with the individual mandate would lead to large-scale withdrawals from coverage and additional adverse selection in the individual insurance market. Those changes would not be so severe as to lead to a breakdown in the market. As with current law, the subsidies provided in the BCRA would be sufficient to ensure enough participation to keep the market stable, although at lower enrollment levels. The revised BCRA would increase average premiums in the individual market before 2020, and then reduce them in the ensuing years. The increase would occur primarily because of the elimination of the penalties associated with the individual mandate, which would lead some healthier insurance enrollees to exit the market. CBO expects average premiums in the individual insurance market to increase by 10 percent in 2019. Beginning in 2020, the BCRA would tie the restructured premium tax credits to plans with an actuarial of 58 percent, compared to 70 percent under current law. As a result, average premiums in 2026 would be about 25 percent below the average under current law. The BCRA [...]

Orphan Diseases Or Population Health? Policy Choices Drive Venture Capital Investments

Fri, 21 Jul 2017 14:57:09 +0000

The US exhibits a remarkable pipeline of biopharmaceutical innovation, with 170 new drugs and biologics launched into the market between 2011 and 2015 and another 22 drugs approved in 2016. A striking feature of the pharmaceutical pipeline is the large percentage launched for the treatment of small “orphan” indications, defined by the Food and Drug Administration (FDA) as including fewer than, often many fewer than, 200,000 patients in the United States. Almost half (74) of the products approved by the FDA between 2011 and 2015 were for orphan indications, twice the number (36) approved during the same period by the European Medicines Agency and a remarkable increase over the total of 35 orphan products approved by the FDA in all the years prior to the Orphan Drug Act of 1983. In 2016, 41 percent of the novel drug approvals were for rare diseases (nine of the 22 approvals). The surge in orphan drugs is a result of public policies that influence development costs and market exclusivity, which in turn influence the prices that can be charged. Early-stage investors in the life sciences pay close attention to policy signals in deciding how to allocate their capital. The policy decisions made yesterday influence investment decisions made today, and hence the direction of innovation tomorrow. Bay City Capital is a venture capital partnership, founded in 1997, that has invested in over 100 life sciences firms worldwide and currently manages $1.3 billion in capital. In recent years it has focused increasingly on drugs rather than medical devices and diagnostics and, within pharmaceuticals, to those addressing narrow rather than broad patient populations — the firm now mostly looks for biotech startups targeting drugs in indications that can be developed all the way to FDA approval, such as orphan areas that enjoy favorable policy treatment with high revenue potential. The benefits of venture capital investment in orphan drugs are very important for patients suffering from rare conditions. As investments shift away from treatments affecting large numbers of patients, however, the potential impact of innovation on public health may be reduced. Even modest improvements in therapies affecting cardiovascular disease, diabetes, or other large indications would offer major population health benefits. In the past, for example, some startups financed by Bay City developed cardiovascular treatments up through early clinical studies, but they were unable to secure a partner to finance the large clinical trials necessary for FDA approval. This post looks at some of the policy and market considerations that encourage Bay City Capital and firms like it to focus their resources on orphan drugs. Policy Initiatives That Reduce Development Cost The FDA requires substantial evidence of effectiveness for a new drug approval, with the standard requirement including two adequate and well-controlled clinical trials. However, the FDA uses its judgment to determine the type and quantity of data needed to meet its standards. In reviewing orphan drugs the FDA routinely allows fewer than two controlled studies, smaller studies, and/or studies that use novel endpoints. Between 2009 and 2013, 60 percent of orphan drugs were approved based on a single trial, compared to only 28 percent for drugs addressing more common conditions. The size of the orphan drug trials typically is much smaller than for non-orphan candidates, involving dozens or hundreds, rather than thousands, of patients. For example, Ravicti™, a drug for Urea Cycle Disorder developed by Bay City portfolio company Hyperion Therapeutics, received approval based on a pivotal efficacy trial that included 45 patients and long-term efficacy and safety studies that totaled 100 patients. Drug firms developing cancer treatments increasingly are launching them in small sub-indications demarcated by biomarkers or clinical criteria t[...]

The Latest CBO Score Of The Better Care Reconciliation Act Leaves 22 Million Uninsured by 2026 (Update)

Thu, 20 Jul 2017 19:27:35 +0000

July 21 Update. The July 21, 2017 Congressional Budget Office report did not score the Cruz amendment to the BCRA. The Cruz amendment would allow insurers to sell plans that would not be required to comply with a number of ACA requirements—including guaranteed issue, community rating, preexisting condition coverage, and the essential health benefits—as long as the insurers sold plans that complied with the ACA. It is reported that the CBO would have to take some time to produce a score, in part no doubt because the ACA non-compliant coverage permitted by the Cruz amendment might not qualify as health insurance coverage under CBO definitions. On July 21, 2017, however, Senators Lee (R-UT) and Johnson (R-WI) circulated to their colleagues a Dear Colleague letter to which they attached an analysis of the Cruz amendment apparently done by the Department of Health and Human Services. (The letter also attaches an analysis of premiums under the ACA done by McKinsey but does not claim that McKinsey is responsible for the Cruz amendment analysis.) The analysis is remarkable because it shows enrollment growing and premiums falling—even for ACA-compliant plans—under the Cruz amendment. A wide range of observers, including insurers, actuaries, insurance regulators, and consumers have criticized the Cruz amendment as unworkable. Much of the methodology on which the HHS analysis is based is proprietary and was not disclosed, so it is difficult to verify. The analysis has been criticized, however, on a number of counts. It compares premiums for a 40-year old under the Cruz amendment with average premiums for a 47-year old under the ACA; it incorporates some elements of the ACA and others of the BCRA in its comparisons in a way that distorts the final analysis, and it ignores some problematic features of the BCRA and assuming away problems that would be created by others. The manifold problems with the analysis, which seems to have been written to support the Cruz amendment, rather than to provide impartial analysis, demonstrate again why it is essential to have a nonpartisan, impartial, referee like the CBO to analyze the effects of proposed legislation, a point made in a July 21 letter to Congress signed by all eight former directors of the CBO. The Latest BCRA Score On July 20, 2017, the Senate Budget committee released the latest version of the Better Care Reconciliation Act (summary), which was sent to the Congressional Budget Office (CBO) for scoring. It is basically identical to the second BCRA draft posted on July 13, 2017 (which was not separately scored by the CBO) except that it drops the Cruz amendment and includes a couple of small changes in the Medicaid section. The July 13 draft added $70 billion in state long-term stabilization funding to the original BCRA which the Cruz amendment then shifted to the Department of Health and Human Services (HHS) to pay to insurers that offered Affordable Care Act compliant plans. By dropping the Cruz amendment, the July 20 draft leaves these funds with the states, and thus increases state long-term stabilization funding by that amount over the July 13 draft. Minutes later on July 20, 2017, the CBO released an analysis of the July 20 BCRA version, as did the Joint Committee on Taxation. The biggest change in their analysis from their first BCRA score, which analyzed the original June 22 version, is that the July 20 version would reduce the federal budget deficit by $483 billion over ten years compared to the $321 billion deficit reduction in the original June 22 BCRA. The biggest reason for the change in the deficit score is that the July 20 version drops provisions of the original BCRA repealing the ACA’s Medicare payroll tax surcharge and unearned income taxes on high wage earners, which would have resulted in the loss of $231 billion in tax revenues. This reduction in lost rev[...]

CMS Releases FAQ On Its New Proxy Direct Enrollment Pathway

Thu, 20 Jul 2017 16:31:34 +0000


In May of 2017, the Centers for Medicare and Medicaid Services (CMS) announced that it intended to make a new proxy direct enrollment pathway available for enrollees for 2018. The guidance provided that direct enrollment (DE) entities would have to be audited by third-party auditors for operational readiness before they could begin offering proxy DE. On July 18, 2017, CMS released at its website (registration required) a series of frequently asked questions regarding the Third Party Operational Readiness Reviews (ORRs) for the Proxy Direct Enrollment Pathway.

In response to the first FAQ, CMS states that if an entity that hires an auditor to conduct an ORR for its approved proxy DE pathway, the same report can produce audit findings that could be used for all DE entities using the identical version of the entities approved proxy DE pathway. The secondary DE entity will have to attest to the accuracy and completeness of the ORR submitted by the entity that is providing the proxy DE pathway, sign the proxy DE agreement, and be responsible for complying with all applicable regulations and guidance, as well as its agreement. If a DE entity using another entity’s approved proxy DE pathway adds additional functionality, it will need to conduct and resubmit the original ORR report with additional findings for the additional functionality.

A second FAQ states that a DE entity may allow third-party agents and brokers who are registered with the federally facilitated exchange to use its approved proxy DE pathways to assist consumers in applying for premium tax credits and cost-sharing reduction payments and for selecting qualified health plans, but only if the third-party has its own proxy DE agreement with CMS. A DE entity may not embed tools or programming techniques in its proxy DE website directing consumers to unapproved websites. Each DE entity is responsible for ensuring compliance with the terms and conditions of its proxy DE agreement by all downstream third-party agents and brokers using its proxy DE pathway.

A third FAQ reiterates CMS guidance that proxy DE enrollment is only available for simple enrollments, and not for complex situations like multi-tax filer households, applications where a Social Security Number is not provided, or applications with non-United States-born citizens.

Finally, a fourth FAQ states that DE entities participating in the proxy pathway must support all household scenarios supported by the streamline application user interface. If in its readiness testing a DE entity identifies an eligibility scenario it cannot support in the proxy DE pathway, it must notify CMS and provide an alternate way for consumers to have their eligibility determined, such as using the exchange, marketplace call center, or the traditional direct enrollment pathway.

Is Medicaid The New ‘Third Rail?’ History Suggests It Has Been For Some Time

Thu, 20 Jul 2017 15:03:37 +0000

As President Trump and Congressional Republicans regroup following the collapse of their efforts to repeal and replace the Affordable Care Act they should look not only at what went wrong with their legislation but also past efforts to reform American health care. While many things went wrong, the biggest stumbling block to the GOP efforts this year was the attempt to dramatically change the Medicaid program, which serves some 70 million Americans. Both the House-passed and pending Senate bills would have replaced the 52-year-old entitlement program with capped federal spending and a state-run block grant. The federal government would continue to share in the program’s costs but annual growth would be tightly limited, leaving states with the job of balancing the health needs of their citizens with the new fiscal realities. While only tangentially related to the ACA, the Medicaid caps and block grants were too much to swallow for many moderate Republicans. For most of its history, Medicaid took a back seat to Medicare, the health benefits program for seniors and others. But now, due to its growth in size and cost Medicaid has gained so much clout that it should be considered the new “third rail” of American politics. To be sure, some politicians have long seen Medicaid as target ripe for cutting federal spending. But many more are leery of touching the program and facing the wrath of the people who elected them. The difficulties encountered by the President, House Speaker Paul Ryan of Wisconsin, and Senate Majority Leader Mitch McConnell of Kentucky are eerily similar to those faced by the nation’s 40th President, Ronald Reagan. Instead of providing a roadmap to victory, the story of Reagan’s efforts is a cautionary tale. Past Is Prologue In 1981, perhaps Reagan’s most successful year of domestic policy legislative victories, a centerpiece of his budget was a plan to repeal the Medicaid entitlement and replace it with a state-run block grant. Federal spending for Medicaid would be sharply reduced and states would be required to make up the difference by cutting millions from the program. Sound familiar? Reagan included his Medicaid block grant proposal in his sweeping plan to cut government spending while reducing taxes across the board. With a new GOP majority in the Senate and a near-majority in the House, Reagan won a string of significant victories that reshaped U.S. domestic policy in ways that moved the nation dramatically to the right and set the tone for the next 20 years of Congressional debates about deficit spending and tax relief. Reagan asked Congress, for the first time, to use a new budget “reconciliation” process to consider his spending and tax policies. The Senate, behind the leadership of Finance Committee Chairman Bob Dole of Kansas, approved the Medicaid block grant as part of its budget reconciliation bill. In the House, however, Reagan’s plan ran into a solid brick wall thanks to the wily leadership of a young Henry Waxman. The California Democrat had only recently taken the helm of the House Health Subcommittee and was determined to preserve the Medicaid entitlement even as he gave way on a number of Reagan’s other health care priorities. Following a heated debate that June, the House approved Reagan’s blueprint for spending cuts with one glaring exception. The Medicaid block grant proposal was pulled from the larger bill and House members were asked to vote on it in isolation. Waxman and his allies worked hard to garner support from governors of both parties, as well as organizations representing doctors, hospitals, drug companies, and others to defeat Reagan’s plan. At the same time, House Republican leaders tried to win the day by tweaking the Medicaid block grant proposal. In the end, the Republicans withdrew the Medicaid reform [...]