Reminder: Medicare Part D Notices Are Due to CMS by Feb. 29

The federal Centers for Medicare & Medicaid Services (CMS) require disclosures regarding coverage that is either "creditable" or "non-creditable" each calendar year. The notice and disclosure deadline for those who provide prescription drug coverage is due February 29, 2020. Read this blog post to learn more about the Medicare Part D notice.


Each year, group health plan sponsors that provide prescription drug coverage to individuals eligible for Medicare Part D must disclose to the federal Centers for Medicare & Medicaid Services (CMS) whether that coverage is "creditable" or "non-creditable." Prescription drug coverage is "creditable" when it is at least actuarially equivalent to Medicare Part D prescription drug coverage.

The disclosure obligation applies to all plan sponsors that provide prescription drug coverage, even those that offer prescription drug coverage only to active employees and not to retirees. Calendar year plans must submit this year's disclosure by Feb. 29, 2020.

Background

Individuals who fail to enroll in Medicare Part D prescription drug coverage when first eligible may be subject to late enrollment penalties if they go 63 consecutive days or longer without creditable prescription drug coverage. Because of this potential penalty, both Medicare Part D-eligible individuals and the CMS need to know whether a group health plan's prescription drug coverage is creditable or non-creditable.

Plan sponsors that provide prescription drug coverage must furnish Part D-eligible individuals with a notice disclosing the creditable or non-creditable status of their coverage before the beginning of the Medicare Part D annual enrollment period and at certain other times.

Plan sponsors must also disclose to CMS, on an annual basis and at certain other times, whether the coverage they provide is creditable or non-creditable. The submission deadline for this year's disclosure to CMS by calendar year plans is approaching.

Creditable Coverage Disclosures to CMS

Plan sponsors generally must disclose creditable coverage status to CMS within 60 days after the beginning of each plan year. Disclosure is made using the Disclosure to CMS Form on the CMS website. An entity that does not offer outpatient prescription drug benefits to any Part D-eligible individual on the first day of its plan year is not required to complete the CMS disclosure form for that plan year. Plan sponsors that contract directly with Medicare as a Part D plan or that contract with a Part D plan to provide qualified prescription drug coverage are also exempt from the CMS disclosure requirement for individuals who participate in the Part D plan.

In addition to the annual disclosure, plan sponsors must submit a new disclosure form to CMS within 30 days following any change in the creditable coverage status of a prescription drug plan. This includes both a change in the coverage offered so that it is no longer creditable (or non-creditable) and the termination of a creditable coverage option. A new disclosure form must also be submitted to CMS within 30 days after the termination of a prescription drug plan.

The disclosure requirement applies to all plan sponsors that provide prescription drug coverage to Part D-eligible individuals, even those that do not make prescription drug coverage available to retirees.

Calendar year plans must submit this year's disclosure to CMS by Feb. 29, 2020.

Is disclosure required If an employer doesn't offer retiree coverage?
All Part D-eligible individuals covered under an employer's prescription drug plan — regardless of whether the coverage is primary or secondary to Medicare Part D — should be included in the disclosure. "Part D-eligible individuals" are generally age 65 and older or under age 65 and disabled, and include active employees and their dependents, COBRA participants and their dependents, and retirees and their dependents. Even employers without retiree coverage may need to file the disclosure.

Information Needed to Complete Disclosure

In preparing the disclosure to CMS, plan sponsors need to:

  • Identify the number of prescription drug options offered to Medicare-eligible individuals. This is the total number of benefit options offered, excluding any benefit options the plan sponsor is claiming under the retiree drug subsidy (RDS) program (i.e., benefit options for which the plan sponsor is expected to collect the subsidy) or that are employer group waiver plans (EGWPs).
    For example, a plan sponsor with a PPO and an indemnity option covering actives and an option for retirees for which it is receiving RDS would report two prescription drug options.
  • Determine the number of benefit options offered that are creditable coverage and the number that are non‑creditable.
  • Estimate the total number of Part D-eligible individuals expected to have coverage under the plan at the start of the plan year (or, if both creditable and non-creditable coverage options are offered, estimate the total number of Part D-eligible individuals expected to enroll in each coverage category). This includes Part D-eligible active employees, retirees, and disabled individuals and any of their Part D-eligible dependents and any individuals on COBRA who are Part D eligible.
    The estimate should not include any Part D-eligible retirees being claimed under the RDS program or retirees in an EGWP (because that coverage is Medicare Part D coverage).
    Individuals who will become Part D eligible after the start of the plan year should not be included in the count for that year. However, they must be provided a notice of creditable or non-creditable coverage prior to their initial Part D enrollment period.
  • Provide the most recent calendar date on which the required notices of creditable or non-creditable coverage were provided.
Why doesn't the disclosure requirement apply to EGWPs or retiree plans where employer is receiving RDS payments?
Employers that provide prescription drug coverage through a Medicare Part D employer group waiver plan are exempt from the disclosure requirement because an EGWP is Medicare Part D coverage.

An employer participating in the retiree drug subsidy program must have already certified to CMS that its drug coverage is creditable.

In Closing

Plan sponsors should review the instructions carefully before completing the Disclosure to CMS Form to make sure that they have all necessary information, and calendar year plans should report the information by Feb. 29, 2020.

Richard Stover, FSA, MAAA, is a principal at HR advisory firm Buck. Leslye Laderman, JD, LLM, is a principal in the Knowledge Resource Center at Buck. This article originally appeared in the Feb. 5, 2020 issue of Buck's For Your Information. © 2020 Buck Global LLC. All rights reserved. Republished with permission.

SOURCE: Stover, R.; Laderman, L. (06 February 2020) "Reminder: Medicare Part D Notices Are Due to CMS by Feb. 29" (Web Blog Post). Retrieved from https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/reminder-medicare-part-d-notices-due-to-cms.aspx


A look at how the opioid crisis has affected people with employer coverage

The opioid crisis is affecting more and more people each day. Discover how the opioid crisis affects you with this study on employer coverage.


With deaths from opioid overdose rising steeply in recent years, and a large segment of the population reporting knowing someone who has been addicted to prescription painkillers, the breadth of the opioid crisis should come as no surprise, affecting people across all incomes, ages, and regions. About four in ten people addicted to opioids are covered by private health insurance and Medicaid covers a similarly large share.

Private insurance covers nearly 4 in 10 non-elderly adults with opioid addiction

In this analysis and a corresponding chart collection, we use claims data from large employers to examine how the opioid crisis has affected people with large employer coverage, including employees and their dependents. The analysis is based on a sample of health benefit claims from the Truven MarketScan Commercial Claims and Encounters Database, which we used to calculate the amounts paid by insurance and out-of-pocket on prescription drugs from 2004 to 2016. We use a sample of between 1.2 and 19.8 million enrollees per year to analyze the change from 2004 to 2016 in opioid-related spending and utilization.

We find that opioid prescription use and spending among people with large employer coverage increased for several years before reaching a peak in 2009. Since then, use of and spending on prescription opioids in this population has tapered off and is at even lower levels than it had been more than a decade ago. The drop-off in opioid prescribing frequency since 2009 is seen across people with diagnoses in all major disease categories, including cancer, but the drop-off is pronounced among people with complications from pregnancy or birth, musculoskeletal conditions, and injuries.

Meanwhile, though, the cost of treating opioid addiction and overdose – stemming from both prescription and illicit drug use – among people with large employer coverage has increased sharply, rising to $2.6 billion in 2016 from $0.3 billion 12 years earlier, a more than nine-fold increase.

Trends in prescription opioid use & spending among people with large employer coverage

Opioid prescription use among people with large employer coverage is highest for older enrollees: 22% of people age 55-64 had at least one opioid prescription in 2016, compared to 12% of young adults and 4% of children. Women with large employer coverage are somewhat more likely to take an opioid prescription than men (15% compared to 12%). Opioid prescription use among people with large employer coverage is also higher in the South (16%) than in the West (12%) or Northeast (11%).

Among people with large employer coverage, older enrollees are more likely to have an opioid prescription

Among people with large employer coverage, the frequency of opioid prescribing increased from 2004 (when 15.7% of enrollees had an opioid prescription) to 2009 (when 17.3% did). After reaching a peak in 2009, the rate of opioid prescribing began to fall. By 2014, the share of people with large employer coverage who received an opioid prescription (15.0%) was lower than it had been a decade earlier, and by 2016, the share was even lower, at 13.6% (a 21% decline since 2009).

The share of people with large employer coverage taking opioid prescriptions is at its lowest levels in over a decade

Among people with large employer coverage, this pattern (of increasing opioid prescription use through the late 2000s, followed by a drop-off through 2016) is similar across most major disease categories. Some of the steepest declines in opioid prescription use since 2009 were among people with complications from pregnancy or childbirth, musculoskeletal conditions, and injuries. The share of people experiencing complications from pregnancy or childbirth who received an opioid prescription peaked in 2007, when 35% received an opioid prescription, but this share dropped to 26% in 2016. Similarly, in 2007, 37% of people with large employer coverage who had a musculoskeletal condition received an opioid prescription, but the share dropped to 30% by 2016. The same decline can be seen among people with large employer coverage who experienced injuries and poisonings (37% in 2009, down to 30% in 2016).

Opioid use declined across disease categories, particularly pregnancy, musculoskeletal diseases, and injuries

We also see a sharp decline in the use of opioid prescriptions among people with cancer diagnoses, particularly in the most recent couple of years. In 2016, 26% of people with large employer coverage who had a cancer diagnosis received at least one opioid prescription, down from 32% in 2007. Despite declines in opioid prescribing for musculoskeletal conditions, people with large employer coverage who have musculoskeletal diagnoses still receive opioid medications more frequently (30%) than those with cancer diagnoses (26%).Overall in 2016, among those receiving an opioid prescription, a slightly larger share received only a single prescription in that year (61%) than did in 2006, a decade earlier (58%). The average number of prescriptions each person received also rose from 2004 until 2010 and then fell again, but this measure is imperfect because it does not adjust for the length of the supply or the strength of the drug received.

In total, large employer plans and their enrollees spent $1.4 billion in 2016 on opioid prescription painkillers, down 27% from peak spending of $1.9 billion in 2009. In 2016, $263 million, or 19% of total opioid prescription drug spending was paid out-of-pocket by enrollees.

Spending on opioid prescriptions peaked in 2009

Opioid prescriptions have represented a small share of total health spending by large employer plans and enrollees.

Treatment for Opioid Addiction & Overdose among People with Large Employer Coverage

In 2016, people with large employer coverage received $2.6 billion in services for treatment of opioid addiction and overdose, up from $0.3 billion in 2004. Of the $2.6 billion spent on treatment for opioid addiction and overdose in 2016 for people with large employer coverage, $1.3 billion was for outpatient treatment, $911 million was for inpatient care, and $435 million was for prescription drugs. In 2016, $2.3 billion in addiction and overdose services was covered by insurance and $335 million was paid out-of-pocket by patients. (This total only includes only payments for services covered at least in part by insurance, not services that are paid fully out-of-pocket and not billed to insurance, so it is likely an undercount of opioid addiction and overdose treatment expenses by this population.)

The cost of treating opioid addiction and overdose has risen even as opioid prescription use has fallen

Spending on treatment for opioid addiction and overdose represents a small but growing share of overall health spending by people with large employer coverage. In 2016, treatment for opioid addiction and overdose represented about 1% of total inpatient spending by people with large employer coverage and about 0.5% of total outpatient spending. In 2004, treatment for opioid addiction and overdose represented about 0.3% of total inpatient spending and less than 0.1% of total outpatient spending. On average, inpatient and outpatient treatment for opioid addiction and overdose added about $26 per person to the annual cost of health benefits coverage for large employers in 2016, up from about $3 in 2004.

The bulk of the total $2.6 billion in spending for treatment of opioid addiction and overdose among people with large employer coverage was treatment for young adults, totaling $1.6 billion in 2016, even though young adults are prescribed opioids less often than older adults. Males also used more treatment than women ($1.6 billion vs $1.0 billion).

Spending on opioid addiction and overdose treatment is mostly concentrated among younger people

The bulk of spending by people with large employer coverage on inpatient and outpatient treatment for opioid addiction and overdose was for employees’ children (53%) or spouses (18%), while just under a third (29%) was for employees themselves.

Among people with large employer coverage who had outpatient spending on treatment for opioid addiction and overdose, their average outpatient expenses totaled $4,695 (of which $670 was paid out-of-pocket) in 2016. Among those with inpatient spending on treatment for opioid misuse, their average inpatient expenses totaled $16,104 (with $1,628 paid out-of-pocket) in 2016. On average, inpatient expenses have risen sharply, up from $5,809 in 2004.

In 2016, 342 people per 100,000 large group enrollees received treatment for opioid overdose or addiction, including 67 people per 100,000 who received treatment in an inpatient setting.

Discussion

Among people with large employer coverage, utilization of opioid prescription painkillers has declined somewhat in recent years. Use of and spending on prescription opioids by this group peaked in 2009 and has since dropped to the lowest levels in over a decade. Across most major disease categories, we see a similar pattern of the frequency of opioid prescription use rising until the late 2000s and then declining through 2016.

Despite declining rates of opioid prescribing to those with employer coverage, spending on treatment for opioid addiction and overdose has increased rapidly, potentially tied to growing illicit use and increased awareness of opioid addiction. Opioid addiction and overdose treatment – the bulk of which is for dependents of employees – represents a small but growing share of overall employer health spending.

Methods

We analyzed a sample of claims obtained from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database (Marketscan).  The database has claims provided by large employers (those with more than 1,000 employees); this analysis does not include opioid prescription or addiction treatment for other populations (such as the uninsured or those on Medicaid or Medicare).  We used a subset of claims from the years 2004 through 2016.  In 2016, there were claims for almost 20 million people representing about 23% of the 85 million people in the large group market.  Weights were applied to match counts in the Current Population Survey for large group enrollees by sex, age, state and whether the enrollee was a policy holder or dependent.  People 65 and over were excluded.

Over 14,000 national drug codes (NDC) were defined as opiates.  In general, we defined “prescription opioids” as those with a primary purpose of treating pain. Only prescriptions classified under the controlled substance act are included. We excluded from this category Methadone, Suboxone (Buprenorphine with Naloxone), and other drugs commonly used to treat addiction.  We also excluded medications not commonly prescribed (such as Pentazocine).  Each opiate script was counted as a single prescription regardless of the quantity or strength of that prescription.  The Marketscan database only includes retail prescriptions administered in an outpatient setting.  Disease categories are defined by AHRQ’s chronic condition indicators, and based on the diagnosis an enrollee receives.

In our analysis of opioid addiction and overdose treatment, we include medications used to treat overdose (e.g. Naloxone) and drugs used to treat addiction (e.g. Methadone and Suboxone). We also include inpatient and outpatient medical services to treat opioid addiction or overdose, identified by ICD-9 and ICD-10 diagnosis codes. Midway through 2015, Marketscan claims transitioned from ICD-9 to ICD-10.  While both systems classify diagnoses, there is no precise crosswalk between the two.  In consultation with a clinician, we selected both ICD-9 and ICD-10 codes which are overwhelmingly used for opioid addiction or signify misuse.  A list of these ICD codes is available upon request.  Because of the change in coding systems, it is not possible to tracks trends between 2014 and 2016.  Diagnoses related to heroin abuse were included as opiate abuse.

Because there is no precise way to identify costs associated with opioid addiction and overdose treatment, some of our rules for inclusion lead to an underestimate, while others lead to an overestimate. In general, we elected a conservative approach. For example, in some cases, opioid abuse diagnoses may be classified under a broader drug abuse diagnosis and therefore are not captured.  Additionally, we do not include the costs associated with diagnoses that commonly arise from opioid abuse, such as respiratory distress or endocarditis, unless an opioid abuse diagnosis was also present.  However, if a claim included an opioid abuse diagnosis along with other diagnoses, we included spending for all procedures during that day, even if some of those interventions were to treat concurrent medical conditions unrelated or indirectly related to opioid abuse.  If an enrollee paid fully out-of-pocket and did not use their insurance coverage, this spending is also not included.  Overall, we think these assumptions lead to an underestimate of the costs associated with opioid addiction and overdose treatment for the large employer coverage population.

SOURCE:
Cox C (24 May 2018). "A look at how the opioid crisis has affected people with employer coverage" Web Blog Post]. Retrieved from address https://www.healthsystemtracker.org/brief/a-look-at-how-the-opioid-crisis-has-affected-people-with-employer-coverage/#item-start


Understanding the Intersection of Medicaid and Work

Sometimes, healthcare is confusing. We know this, which is why today we are focusing on Medicaid and work. Check out the snippet below, and check out the link for the full article.


Medicaid is the nation’s public health insurance program for people with low incomes. Overall, the Medicaid program covers one in five Americans, including many with complex and costly needs for care. Historically, nonelderly adults without disabilities accounted for a small share of Medicaid enrollees; however, the Affordable Care Act (ACA) expanded coverage to nonelderly adults with income up to 138% FPL, or $16,642 per year for an individual in 2017. As of December 2017, 32 states have implemented the ACA Medicaid expansion.1 By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. While many have gained coverage under the expansion, the majority of Medicaid enrollees are still the “traditional” populations of children, people with disabilities, and the elderly.

Some states and the Trump administration have stated that the ACA Medicaid expansion targets “able-bodied” adults and seek to make Medicaid eligibility contingent on work. Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states are seeking waiver authority to do so.  These types of waiver requests were denied by the Obama administration, but the Trump administration has indicated a willingness to approve such waivers. This issue brief provides data on the work status of the nearly 25 million non-elderly adults without SSI enrolled in Medicaid (referred to as “Medicaid adults” throughout this brief) to understand the potential implications of work requirement proposals in Medicaid.  Key takeaways include the following:

  • Among Medicaid adults (including parents and childless adults — the group targeted by the Medicaid expansion), nearly 8 in 10 live in working families, and a majority are working themselves. Nearly half of working Medicaid enrollees are employed by small firms, and many work in industries with low employer-sponsored insurance offer rates.
  • Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work including illness or disability or care-giving responsibilities.
  • While proponents of work requirements say such provisions aim to promote work for those who are not working, these policies could have negative implications on many who are working or exempt from the requirements. For example, coverage for working or exempt enrollees may be at risk if enrollees face administrative obstacles in verifying their work status or documenting an exemption.

Get the full report and findings.

SOURCE:
Kaiser Family Foundation (5 January 2018). "Understanding the Intersection of Medicaid and Work" [Web Blog Post]. Retrieved from address https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/

Some States Roll Back ‘Retroactive Medicaid,’ A Buffer For The Poor — And For Hospitals

From Kaiser Health News, let's take a look at the latest regarding Medicaid.


If you’re poor, uninsured and fall seriously ill, in most states if you qualify for Medicaid — but weren’t enrolled at the time — the program will pay your medical bills going back three months. It protects hospitals, too, from having to absorb the costs of caring for these patients.

But a growing number of states are rescinding this benefit known as “retroactive eligibility.” On Nov. 1, Iowa joined three states that have eliminated retroactive coverage for some groups of Medicaid patients since the Affordable Care Act passed. Each state had to secure approval by the federal government.

Retroactive eligibility has been a feature of Medicaid for decades, reflecting the program’s emphasis on providing a safety net for poor, disabled and other vulnerable people. In contrast to private insurance, determining Medicaid eligibility can be complex and the application process daunting, advocates say. A patient’s medical condition also may keep families from applying promptly for coverage.

All four states — Arkansas, Indiana and New Hampshire, in addition to Iowa — have expanded Medicaid under the health law, which allowed states to include adults with incomes up to 138 percent of the federal poverty level, or about $16,000 for one person. So, in theory, most adults are required to have insurance under the ACA. In practice, each state still has a significant number of uninsured, ranging from 5 to 8 percent of the population.

The retroactive coverage “can compensate for the sorts of errors and lapses that can so easily occur on the part of both the applicant and the government bureaucracy” that delay applications, said Gordon Bonnyman, staff attorney at the Tennessee Justice Center, a public interest law firm that represents low-income and uninsured residents.

State and federal officials say eliminating the retroactive coverage helps encourage people to sign up for and maintain coverage when they’re healthy rather than waiting until they’re sick to enroll. It also fits into federal officials’ efforts to make Medicaid, the federal-state program that provides health care for low-income adults and children, more like private insurance.

But consumer advocates and health care providers say the shift will saddle patients with hefty medical bills and leave hospitals to absorb more uncompensated care when patients can’t pay. Some worry this could be the start of a trend.

In Iowa, the change applies to just about anyone coming into Medicaid — except for pregnant women and children under age 1. The change will affect up to 40,000 residents annually and save the program more than $36 million a year.

“We’re making it a lot more likely that Medicaid-eligible members are going to incur significant medical debt,” said Mary Nelle Trefz, health policy associate at the Child & Family Policy Center in Des Moines, whose organization opposed the change.

When someone has a traumatic health event, the initial focus is to get them stabilized, not figure out how to pay for it, said MaryBeth Musumeci, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Patients may neglect to apply immediately for Medicaid, leaving them financially responsible for days or months of care they received before they got in their application, even though they may have been eligible for Medicaid all along.

That’s not the only issue, advocates say. Unlike the commercial insurance market where re-enrollment through someone’s employer is routine, Medicaid requires that beneficiaries’ eligibility be reassesed every year.

“People fall through the cracks,” said Andrea Callow, associate director of Medicaid initiatives at Families USA, a consumer advocacy group.

In addition, complications can arise for people who might need Medicaid coverage for long-term care services. “The criteria are complicated. For a layperson to find those criteria and figure out if they’re eligible” is challenging and they may need extra time, said Musumeci. Once patients have secured coverage, they may already have accrued hefty expenses.

Maybe so, but some people argue that a 90-day retroactive eligibility guarantee is counterproductive.

“We’re trying to get people to behave more responsibly, not less responsibly,” said Gail Wilensky, an economist who oversaw the Medicaid and Medicare programs in the early 1990s under President George H.W. Bush. “That is not the signal you’re sending” with three months of retroactive eligibility. A 30-day time frame is more reasonable, Wilensky said.

In contrast to Iowa, the waivers in Arkansas, Indiana and New Hamsphire generally apply only to adults who gained coverage under the law’s Medicaid expansion. (Indiana’s waiver also applies to other groups.)

Kentucky has a request pending that, like Iowa, would eliminate retroactive Medicaid eligibility except for pregnant women and children under 1, according to KFF.

Under federal law, officials can waive some Medicaid coverage rules to give states flexibility to experiment with different approaches to providing services. And retroactive eligibility waivers in Medicaid are hardly new. A few states like Tennessee have had them in place for years. Tennessee officials eliminated retroactive eligibility for all Medicaid beneficiaries in 1994 when the state significantly expanded coverage under TennCare, as Medicaid is known there. At the time, the state even allowed uninsured people to buy into the program who wouldn’t otherwise qualify based on income, said Bonnyman.

“There was no reason for anybody to be uninsured except undocumented immigrants,” said Bonnyman. “It didn’t seem to have the potential for harm.”

But state officials revamped that program after serious financial problems. Eligibility for TennCare has become more restrictive again.

Other states that waived retroactive coverage for at least some Medicaid groups include Delaware, Maryland, Massachusetts and Utah, according to the Kaiser Family Foundation.

Bonnyman said his group frequently works with Medicaid beneficiaries who have medical bills they can’t afford that accumulated during the months before they applied for Medicaid.

“If you’re a moderate- to low-income working family, one or two days in the hospital is enough to ruin you financially,” he said.

 

You can read the original article here.

Source:
Andrews M. (14 November 2017). "Some States Roll Back ‘Retroactive Medicaid,’ A Buffer For The Poor — And For Hospitals" [Web blog post]. Retrieved from address https://khn.org/news/some-states-roll-back-retroactive-medicaid-a-buffer-for-the-poor-and-for-hospitals/


10 Things to Know about Medicaid: Setting the Facts Straight

Do you need help understanding all the aspects of Medicaid? Check out this informative article by Julia Paradise from Kaiser Family Foundation about the 10 most important things you must know when dealing with Medicaid.

Medicaid, the nation’s public health insurance program for low-income children, adults, seniors, and people with disabilities, covers 1 in 5 Americans, including many with complex and costly needs for medical care and long-term services. Most people covered by Medicaid would be uninsured or underinsured without it. The Affordable Care Act (ACA) expanded Medicaid to reach low-income adults previously excluded from the program and provided federal funding to states for the vast majority of the cost of newly eligible adults.

President Trump and other GOP leaders have called for far-reaching changes to Medicaid, including caps on federal funding for the program. In the debate about Medicaid’s future, some critics of the program have made statements that are at odds with data, research, and basic information about Medicaid. To inform policy decisions that may have significant implications for Medicaid, the low-income people it serves, and the states, this brief highlights 10 key Medicaid facts.

1.    Medicaid is a cost-effective program, providing health coverage for low-income Americans at a lower per-person cost than private insurance could.

Some say that Medicaid costs too much. Total Medicaid costs are high because Medicaid covers many people with complex needs for both health care and long-term care. Most Medicaid spending is for seniors and people with disabilities (Figure 1). Analysis shows that when the greater health needs of Medicaid enrollees are adjusted, costs per enrollee are lower in Medicaid relative to private insurance; spending per enrollee would be 25% higher if adult Medicaid beneficiaries were instead covered by employer-based insurance, largely because private insurers generally pay providers more than states do. Growth in Medicaid acute care spending per enrollee has also been low relative to other health spending benchmarks, and federal data show that Medicaid has constrained per capita spending growth more than Medicare and private insurance. States have strong financial incentives to manage Medicaid closely and ensure program integrity because they must pay a large share of Medicaid costs and must also balance their budgets. The ACA provided increased funding and new tools for both federal and state Medicaid program integrity efforts, and states continue to strengthen their operations, using data analytics and predictive modeling, expanding their program integrity activities to managed care, and making other investments.

2.    Medicaid bolsters the private insurance market by acting as a high-risk pool.

Some say that private insurance could do a better job of covering low-income people than Medicaid. Actually, Medicaid was established to provide health coverage for many uninsured people who were excluded from the private, largely employment-based health insurance system because of low income, poor health status, or disability. Over time, federal and state expansions of Medicaid have resulted in historic reductions in the share of children without coverage and, in the states adopting the ACA Medicaid expansion, sharp declines in the share of adults without coverage. Nearly 8 in 10 nonelderly, non-disabled adults are in working families and a majority are working themselves, but many work in small firms and types of industries that tend to have limited or no job-based coverage options. Among adult Medicaid enrollees who are not working, illness or disability is the main reason. By covering many of the poorest and sickest Americans, Medicaid effectively serves as a high-risk pool for the private health insurance market, taking out the highest-cost people, thereby helping to keep private insurance premiums more affordable.

Medicaid also bolsters the private insurance system by providing supplemental coverage for many privately insured children with special needs and children and adults with disabilities. Medicaid pays for therapies, dental and vision care, and other medical and long-term services and supports needed by many of these individuals but typically not covered by private insurance.

3.    Federal Medicaid matching funds support states’ ability to meet changing coverage needs, such as during economic downturns and public health emergencies.

Some argue that federal funding for Medicaid should be capped to remove states’ incentives to spend more. The availability of federal matching funds with no pre-set limit does not mean that states have no incentives to constrain spending. On the contrary, because they must spend their own dollars to claim federal matching payments, and are required by their constitutions to balance their budgets, states have a strong interest in running efficient and effective programs. State cost-cutting measures taken in hard economic times have led to lean Medicaid operations, and state Medicaid programs have been leaders in health care delivery and payment reform designed to control costs and improve care. Over 2007-2013, average annual growth in Medicaid spending per enrollee was  less than growth in private health insurance premiums – 3.1% compared to 4.6%.

The guarantee of federal matching funds at least dollar for dollar enlarges states’ financial capacity to respond to changing coverage needs. Because federal funds flow to states based on actual needs and costs, Medicaid can respond if there is an economic downturn, or medical costs rise, or there is a public health emergency such as the opioid epidemic or a natural disaster such as Hurricane Katrina. Federal payments to states adjust automatically to reflect the increased costs of the program. Capped federal funding for Medicaid would reduce federal spending, but the burden of the reductions would fall on states. The levers that states have to manage with reduced federal Medicaid funding are cuts in Medicaid eligibility and benefits, which could limit their ability to meet the health needs of their residents, respond to recessionary pressures and emerging health issues, and provide access to new but costly health care technologies, including life-saving drugs, to Medicaid beneficiaries. Federal caps would also lock in states’ historical spending patterns, constraining their flexibility to respond to changing resources and priorities.

4.    Medicaid is a major spending item in state budgets, but also the largest source of federal funds for states.

Some say that Medicaid is crowding out state spending on education and other state priorities. Medicaid is a major item in state budgets, but it is also the single largest source of federal funds for states. In FY 2015, Medicaid accounted for more than half (57%) of all federal funds states received. The federal government matches state Medicaid spending at least dollar for dollar and pays more in poorer states, and states receive an enhanced federal match – 95% in 2017 – for Medicaid expansion adults. In FY 2015, Medicaid accounted for 28% of total state spending (i.e., including state spending of federal dollars), but less than 16% of state spending of state funds – a distant second to state funds spending on K-12 education (almost 25%).

An analysis examining economic and fiscal trends in Medicaid expansion and non-expansion states found that Medicaid expansion states, which typically raise more tax revenues as a share of total taxable resources than non-expansion states, spend more per capita on both Medicaid and K-12 education. Research shows that the injection of federal Medicaid matching funds into state economies has a multiplier effect, directly benefiting the health care providers that serve Medicaid beneficiaries, and also indirectly supporting other businesses and industries (e.g., vendors), producing increased state economic activity and output as the funds flow through the system. More recent analyses find positive effects of the Medicaid expansion on multiple economic outcomes in states, including budget savings, revenue gains, and overall economic growth.

5.    States have broad discretion in designing key aspects of their Medicaid programs.

Some say that Medicaid is federally controlled and inflexible, leaving states little room to shape their own programs. In fact, beyond federal minimum requirements for Medicaid, states have and use extensive flexibility and options to design key dimensions of their Medicaid programs. For example, they can and do elect to cover many optional services and optional groups. State Medicaid programs vary widely in terms of who is eligible, which services are covered, premiums and cost-sharing requirements, the delivery systems in which beneficiaries get care, and provider payment methods and rates. The different program design choices that states make, reflecting their particular needs, preferences, and priorities, are a large underlying factor in the wide variation in state Medicaid spending per enrollees (Figure 5). In 2011, Medicaid spending per full-benefit enrollee ranged from $4,010 in Nevada to $11,091 in Massachusetts. In addition to the flexibilities and optional state authorities provided by federal Medicaid law, states can obtain Section 1115 demonstration waivers that permit them to test and implement approaches that deviate from federal Medicaid rules if the HHS Secretary determines they advance program objectives. As of January 2017, 37 states had a total of 50 approved Section 1115 waivers.

6.    Medicaid beneficiaries have robust access to care overall, although access to certain types of specialists is an ongoing challenge for Medicaid and all payers.

Some say that access to care in Medicaid is lacking because 30% of physicians do not accept new Medicaid patients (about 70% do accept new Medicaid patients versus about 85% who accept new privately insured and Medicare patients). Taken alone, physician participation rates are a weak measure of access to care. A large body of research shows that Medicaid beneficiaries have far better access to care than the uninsured and are far less likely to postpone or go without needed care due to cost. Moreover, rates of access to care and satisfaction with care among Medicaid enrollees are comparable to rates for people with private insurance (Figure 6). Gaps in access to certain providers, especially psychiatrists, some specialists, and dentists, are ongoing challenges in Medicaid and often in the health system more broadly. Contributing factors include provider shortages, geographic maldistribution of health care providers, low Medicaid payment rates, and lack of transportation. Managed care plans, which now serve most Medicaid beneficiaries, are responsible under their contracts with states for ensuring adequate provider networks. There is no evidence that physician participation in Medicaid is declining. In a 2015 survey, 4 in 10 PCPs who accepted Medicaid reported seeing an increased number of Medicaid patients since January 2014, when the coverage expansions in the ACA took full effect. A recent analysis found no consistent evidence that increases in the share of adults with insurance at the local-area level affected access to care for adults in those areas who were already insured, including Medicaid beneficiaries.

7.    Medicaid keeps coverage and care affordable for low-income Americans.

Some say that Medicaid enrollees should pay more for their health care and have more “skin in the game” to restrain utilization. Federal law limits Medicaid premiums and cost-sharing to minimize financial barriers to coverage and care for low-income people: total out-of-pocket costs for a family are limited to 5% of the family’s income. Research shows that average spending greatly exceeds average income in low-income households, suggesting that these households accrue debt even as they earn. Therefore, even small amounts of spending on health care can crowd out other necessities or push low-income families further into debt. A family of three living at 138% FPL (the eligibility threshold for adults in Medicaid expansion states) has income of $28,180. Out-of-pocket costs totaling just 3% of their income – about $845 – would leave this family with less than $27,500 to pay for housing, utilities, food, clothing, transportation, school supplies, and other necessities. The same family living in one of the non-expansion states, where the median eligibility limit for parents is 44% FPL, would be left with about $8,700 to meet these basic costs.

Numerous studies have shown significant declines in enrollment in coverage after the implementation of new or higher premiums, as well as shorter spells of enrollment and reduced rates of renewal (Figure 7). Many who lose coverage become uninsured. Cost-sharing has been shown to lead to significant reductions in use of services, including essential and effective services like screenings and preventive care, prescription drugs, inpatient care, and other care key to health outcomes. Cost-sharing can have a particularly large impact on people with lower income and significant health care needs, as small copays add up quickly. Medicaid providers frequently report difficulty collecting cost-sharing, which effectively reduces their reimbursement; states do not collect much revenue from premiums, and state savings are largely attributable to decreased enrollment and reduced use of services – often, needed services. The Oregon Health Insurance Experiment (OHIE) showed that gaining Medicaid virtually eliminated catastrophic out-of-pocket medical spending among previously uninsured adults and reduced financial hardship. Federal action to reduce financial protections in

Medicaid would run counter to the empirical evidence that premiums and cost-sharing impede coverage and access to care, and preempt waiver initiatives underway in numerous states to further test these policies.

8.    Evidence of Medicaid’s impact on health outcomes is growing.

Some say that having Medicaid is worse than being uninsured. In fact, research shows consistently that Medicaid improves access to care for both children and adults with low income. Access to screening and preventive care in Medicaid translates into well-child care, earlier detection of health and developmental problems in children, and earlier diagnosis of cancer, diabetes, mental illness, and other chronic conditions in people of all ages. Access to primary care providers and specialists, prescription drugs, and other services improves the likelihood that Medicaid enrollees will get treatment for both their acute and chronic conditions. Expansions of Medicaid pregnant women and children have led to improved birth outcomes and child health, and there is growing evidence that Medicaid expansions to adults are associated with increased use of screening services and preventive care, prescription drugs, inpatient care, and other services key to improving health outcomes (Figure 8). The OHIE, which used a uniquely rigorous study design, found that uninsured adults who gained Medicaid coverage through a state lottery reported improved self-rated mental health and had a 30% reduction in clinically observed rates of depression relative to the comparison group of adults who remained uninsured. Medicaid also increased diabetes detection and use of diabetes medication, though the effect on control of diabetes, hypertension, and high cholesterol was not statistically significant. Research has also found that Medicaid expansions for adults were associated with significant reductions in mortality. A new study shows meaningful impacts of the Medicaid expansion on mental health for low-income parents. Some Medicaid critics, citing a small sample of observational clinical studies, have asserted that Medicaid beneficiaries have worse outcomes than the uninsured. However, a group of distinguished health services researchers commenting in a leading medical journal wrote that these studies lack a causal model explaining the observed data and, outlining numerous analytic problems with the critics’ interpretation of the findings, effectively discredited their argument.

9.    Medicaid is the primary payer for long-term care for seniors and people with disabilities.

Some assume that Medicare, the federal health insurance program for seniors and people with disabilities, covers long-term care. In fact, Medicare coverage of long-term care is extremely limited. Medicaid is essentially the only public or private insurance program that covers long-term care. Six in 10 nursing home residents are covered by Medicaid, and Medicaid’s role in providing access to community-based long-term services and supports (LTSS) for both seniors and people with disabilities is hard to overstate. The program is the largest single source of payment for long-term care, financing half of total spending in this sector, including both nursing home care and home and community-based services (HCBS) (Figure 9). Over time, states have been working to rebalance their LTSS systems by devoting a greater percentage of their long-term care spending to HCBS relative to nursing home care, and Medicaid has been instrumental in expanding access to community-based LTSS, advancing efforts to increase community integration of seniors and individuals with disabilities.

In addition to covering LTSS, Medicaid also makes Medicare work for nearly 10 million poor Medicare beneficiaries (1 in 5 of all Medicare beneficiaries), known as “dual eligibles,” by helping with their Medicare premiums and out-of-pocket costs and covering vision and dental care and other benefits that Medicare does not cover. In the debate about the ACA Medicaid expansion to low-income adults, some have argued that state choices to adopt the expansion come at the cost of Medicaid’s neediest beneficiaries, but the research does not bear this out. A recent study found no evidence for the claim that Medicaid expansion leads to longer waiting lists for Medicaid HCBS waivers for seniors and people with disabilities. The study found that waiting lists for these waivers pre-date the ACA Medicaid expansion, and that there appears to be no relationship between a state’s Medicaid expansion status and changes in its HCBS waiver waiting list.

10. Medicaid is popular with the American public as well as with enrollees themselves.

Some say that Medicaid is a poor and broken program. The majority of Americans say that Medicaid is a very important program. More than half (56%) report that they, a child of theirs, or another family member or friend has been enrolled in Medicaid; the same percentage say that Medicaid is important for them and their family (Figure 10). Most Medicaid enrollees say the program is working well for the low-income people it covers and the vast majority feel well-protected financially. Focus group research has shown high levels of satisfaction with Medicaid among parents with children in the program. Two-thirds of Americans do not support caps on federal funding for Medicaid, the vast majority (84%) say that continuing federal funding for Medicaid expansion is important, and few (12%) want decreased federal spending on Medicaid.

See the original article Here.

Source:

Paradise J. (2017 May 9). 10 things to know about medicaid: setting the facts straight [Web blog post]. Retrieved from address http://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/


Concerned About Losing Your Marketplace Plan? ACA Repeal May Take Awhile

Worried about your healthcare plan? Check out this interesting article from Kaiser Health News, by Michelle Andrews

President-elect Donald Trump has promised that he’ll ask Congress to repeal the Affordable Care Act on Day One of his administration. If you’re shopping for coverage on the health insurance marketplace, should you even bother signing up? If everything’s going to change shortly after your new coverage starts in January anyway, what’s the point?

While it’s impossible to know exactly what changes are coming to the individual market and how soon they’ll arrive, one thing is virtually certain: Nothing will happen immediately. Here are answers to questions you may have.

Q. How soon after Trump takes office could my marketplace coverage change?

It’s unlikely that much, if anything, will change in 2017.

“It’s a complex process to alter a law as complicated as the ACA,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. It seems unlikely that congressional Republicans could force through a repeal of the law since Democrats have enough votes to sustain a filibuster blocking that move. So Congress might opt to use a budget procedure, called “reconciliation,” that allows revenue-related changes, such as eliminating the premium tax credits,  with simple majority votes. Yet even that process could take months.

And it wouldn’t address the other parts of the health law that reformed the insurance market, such as the prohibition on denying people coverage if they’re sick. How some of those provisions of the law will be affected is still quite unclear.

“It will likely be January 2019 before any new program would be completely in place,” said Robert Laszewski, a health care industry consultant and long-time critic of the law.

The current open enrollment period runs through January 2017. Shop for a plan, use it and don’t focus on what Congress may do several months from now, Rosenbaum advised.

Q. Will my subsidy end next year if the new administration repeals or changes the health law?

Probably not. Mike Pence, the vice president-elect, said on the campaign trail that any changes will allow time for consumers receiving premium subsidies to adjust.

Timothy Jost, an emeritus professor at Washington and Lee University School of Law in Virginia who is an expert on the health law, also predicts a reasonable transition period.

Congress and the new administration are “not eager to have a bunch of angry, uninsured voters,” Jost said.

Theoretical conversations about changing the health law are one thing, but “I think that Congress may be less willing to just wipe the subsidies out if a lot of people are using them,” Rosenbaum said. More than 9 million people receive subsidies on the marketplace, according to the federal Department of Health and Human Services.

Q. Can my insurer drop out once the new administration takes over, even if the law hasn’t been repealed?

No, insurers are generally locked in contractually for 2017, according to experts. But 2018 could be a whole different story, said Laszewski.

Many insurers are already losing money on their marketplace offerings. If they know that the health insurance marketplaces are being eliminated and replaced by something else in 2019, why would they stick with a sinking ship?

“The Trump administration could be left with a situation where Obamacare is still alive, the subsidies are still alive, but not the insurers,” said Laszewski. To prevent that, the Trump administration might have to subsidize insurers’ losses during a 2018 transition year, he said.

Q. My state expanded Medicaid to adults with incomes up to 138 percent of the federal poverty level (about $16,000). Is that going to end if Obamacare is repealed?

It may. Trump has advocated giving block grants to finance the entire Medicaid program on the theory that it provides an incentive for states to make their programs more cost-effective. But that strategy could threaten the coverage of millions of Americans if the block grants don’t keep pace with costs, Jost said.

So far, 31 states and the District of Columbia have expanded Medicaid under the health law. Republican governors in these states may play a key role in arguing against taking the expansion money away, Rosenbaum said.

Q. I have a heart condition. Does this mean I’m going to have a hard time finding coverage?

It’s possible. The health law prohibits insurers from turning people away because they’re sick and may be expensive to insure.

Republicans have generally promised to maintain that guaranteed insurability, but what that would look like is unclear. Some of their plans would require people to remain continuously insured in order to maintain that guarantee, said Laszewski.

“I would advise people who are sick to get good coverage now and hang onto it,” said Jost.

Q. Since Republicans have pledged to repeal the law, can I ignore the law’s requirement that I have health insurance?

The individual mandate, as it’s called, is one of the least popular elements of Obamacare. As long as it’s the law, you should follow it, experts said.

Insurers have argued that the requirement that they take all comers who apply for health insurance only works if there’s a coverage mandate or other mechanism that strongly encourages people to have insurance. Otherwise why would they bother unless they were sick?

For the past few years, Republicans have been pushing hard to eliminate the mandate, Laszewski noted.

“One of the easy things they could do is just not enforce it,” he said.

See the original article Here.

Source:

Andrews, M. (2016 November 10). Concerned about losing your marketplace plan? ACA repeal may take awhile [Web blog post]. Retrieved from address http://khn.org/news/concerned-about-losing-your-marketplace-plan-aca-repeal-may-take-awhile/


Kaiser Family Foundation finds states refusing Medicaid expansion paying more

The Kaiser Family Foundation surveyed Medicaid directors in all 50 states to get an overview of how the Affordable Care Act and its implementation is affecting the program.

Today, KFF posted the results of the survey on their website. The extensive report focuses on state Fiscal Year 2015 and state Fiscal Year 2016.

NPR.org offers a synopsis of the findings. The bottom line: the 22 states that didn't expand Medicaid eligibility as part of Obamacare last year saw their costs increase twice as fast as states that extended benefits to more low-income residents.

kaiser

Those states not broadening their Medicaid coverage saw costs rise 6.9 percent in the fiscal year that ended Sept. 30. The 29 states that accepted the offer for President Obama to foot the bill for expanding Medicaid only saw a 3.4 percent rise in cost.

Those states with the modest increase in cost saw Medicaid participation grow by 18 percent. That's 3 times as much as the states that sat out.

Before Obamacare, Medicaid was not an option for able-bodied adults who didn't ahve children. The expansion opened the door to all adults with incomes up to 138 percent of the povertly level to enroll. In 2015, the federal government paid the entire bill for those people. Next year, the federal share tapers to 90 percent.

The Medicaid enrollment is expected to slow down in 2016, according to the KFF survey.

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Click here to read the Kaiser Family Foundation survey report.


Supreme Court debates future of Affordable Care Act

Originally posted on March 5, 2015 by Ariane de Vogue on www.wqad.com.

WASHINGTON (CNN) — The future of health care in America is on the table — and in serious jeopardy — Wednesday morning in the Supreme Court.

After more than an hour of arguments, the Supreme Court seemed divided in a case concerning what Congress meant in one very specific four-word clause of the Affordable Care Act with respect to who is eligible for subsidies provided by the federal government to help people buy health insurance.

If the Court ultimately rules against the Obama administration, more than 5 million individuals will no longer be eligible for the subsidies, shaking up the insurance market and potentially dealing the law a fatal blow. A decision likely will not be announced by the Supreme Court until May or June.

All eyes were on Chief Justice John Roberts — who surprised many in 2012 when he voted to uphold the law — he said next to nothing, in a clear strategy not to tip his hand either way.

“Roberts, who’s usually a very active participant in oral arguments, said almost nothing for an hour and a half,” said CNN’s Supreme Court analyst Jeffrey Toobin, who attended the arguments. “(Roberts) was so much a focus of attention because of his vote in the first Obamacare case in 2012 that he somehow didn’t want to give people a preview of how he was thinking in this case. … He said barely a word.”

The liberal justices came out of the gate with tough questions for Michael Carvin, the lawyer challenging the Obama administration’s interpretation of the law, which is that in states that choose not to set up their own insurance exchanges, the federal government can step in, run the exchanges and distribute subsidies.

Carvin argued it was clear from the text of the law that Congress authorized subsidies for middle and low income individuals living only in exchanges “established by the states.” Just 16 states have established their own exchanges, but millions of Americans living in the 34 states are receiving subsidies through federally facilitated exchanges.

But Justice Elena Kagan, suggested the law should be interpreted in its “whole context” and not in the one snippet of the law that is the focus of the challengers.

“We look at the whole text. We don’t look at four words,” she said. Kagan also referred to the legal challenges to the law as the “never-ending saga.”

Justice Sonia Sotomayor was concerned that in the states where the individuals may not be able to receive subsidies, “We’re going to have the death spiral that this system was created to avoid.”

And Sotomayor wondered why the four words that so bother the challengers did not appear more prominently in the law. She said it was like hiding “a huge thing in a mousetrap.”

“Do you really believe that states fully understood?” she asked, Carvin, that those with federally run exchanges “were not going to get subsidies?”

Justice Ruth Bader Ginsburg suggested the four words at issue were buried and “not in the body of the legislation where you would expect to find” them.

Justice Anthony Kennedy asked questions that could be interpreted for both sides, but he was clearly concerned with the federalism aspects of the case.

“Let me say that from the standpoint of the dynamics of Federalism,” he said to Carvin. “It does seem to me that there is something very powerful to the point that if your argument is accepted, the states are being told either create your own exchange, or we’ll send your insurance market into a death spiral.”

He grilled Carvin on the “serious” consequences for those states that had set up federally-facilitated exchanges.

“It seems to me that under your argument, perhaps you will prevail in the plain words of the statute, there’s a serious constitutional problem if we adopt your argument,” Kennedy said.

The IRS — which is charged with implementing the law — interprets the subsidies as being available for all eligible individuals in the health exchanges nationwide, in both exchanges set up by the states and the federal government. In Court , Solicitor General Donald B. Verrilli, Jr. defended that position. He ridiculed the challengers argument saying it “revokes the promise of affordable care for millions of Americans — that cannot be the statute that Congress intended.”

But he was immediately challenged by Justice Antonin Scalia.

“It may not mean the statute they intended, the question is whether it’s the statute they wrote,” he said.

Although as usual, Justice Clarence Thomas said nothing, Justice Samuel Alito was also critical of Verrilli’s argument. He said if it were true that some of the states were caught off guard that the subsidies were only available to those in state run exchanges, why didn’t more of them sign amicus briefs. And he refuted the notion that the sky might fall if the challengers were to prevail by saying the Court could stay any decision until the end of the tax season.

On that point Scalia suggested Congress could act.

“You really think Congress is just going to sit there while all of these disastrous consequences ensue?” he asked.

Verrilli paused and to laughter said, “Well, this Congress? ”

Kennedy did ask Verrilli a question that could go to the heart of the case wondering if it was reasonable that the IRS would have been charged with interpreting a part of the law concerning “billions of dollars” in subsidies.

Only Ginsburg brought up the issue of standing — whether those bringing the lawsuit have the legal right to be in Court which suggested that the Court will almost certainly reach the mandates of the case.

President Barack Obama has expressed confidence in the legal underpinning of the law in recent days.

“There is, in our view, not a plausible legal basis for striking it down,” he told Reuters this week.

Wednesday’s hearing marks the third time that parts of the health care law have been challenged at the Supreme Court.

In this case — King v. Burwell — the challengers say that Congress always meant to limit the subsidies to encourage states to set up their own exchanges. But when only 16 states acted, they argue the IRS tried to move in and interpret the law differently.

Republican critics of the law, such as Texas Sen. Ted Cruz, filed briefs warning that the executive was encroaching on Congress’ “law-making function” and that the IRS interpretation “opens the door to hundreds of billions of dollars of additional government spending.”

In a recent Washington Post op-ed, Orrin Hatch, R-Utah, and two other Republicans in Congress said that if the Court rules in their favor, “Republicans have a plan to protect Americans harmed by the administration’s actions.”

Hatch said Republicans would work with the states and give them the “freedom and flexibility to create better, more competitive health insurance markets offering more options and different choices.”

In Court, Verrilli stressed that four words — “established by the state” — found in one section of the law were a term of art meant to include both state run and federally facilitated exchanges.

He argued the justices need only read the entire statute to understand Congress meant to issue subsidies to all eligible individuals enrolled in all of the exchanges.

Democratic congressmen involved in the crafting of the legislation filed briefs on behalf of the government arguing that Congress’ intent was to provide insurance to as many people as possible and that the challengers’ position is not consistent with the text and history of the statute.

Last week, Health and Human Services Secretary Sylvia Mathews Burwell warned that if the government loses it has prepared no back up plan to “undo the massive damage.”


Most newly insured Americans covered by employers, study finds

Originally posted April 8, 2014 on www.modernhealthcare.com by Virgil Dickson.

More than 9 million Americans obtained health insurance between September and mid-March, but most did so through employer-sponsored plans rather than through HealthCare.gov or the state exchanges, a survey by the RAND American Life Panel found.

Only 1.4 million of the 3.9 million individuals who enrolled in Patient Protection and Affordable Care Act-related exchange plans through mid-March were previously uninsured, researchers found. The survey concluded before the final enrollment surge that pushed overall marketplace enrollment past 7 million, RAND noted.

Of the 40.7 million estimated uninsured Americans in 2013, 14.5 million gained coverage, but 5.2 million of the insured lost coverage, for a net coverage gain of approximately 9.3 million. That means the share of the population that was uninsured fell from 20.5% to 15.8%, according to RAND.

Less than 1 million citizens who previously had individual market coverage became uninsured, researchers found. RAND was unable to deduce if those people lost their insurance due to cancellation, or because coverage costs were too high. People in this category represented less than 1% of those between the ages of 18 and 64.

Overall, the ACA did not change health coverage choices for most insured Americans, as 80% of those surveyed still had the same type of coverage in March 2014 as in September 2013, according to RAND.

The RAND figures comprised not only signups under the new ACA-established marketplaces, but also new enrollments in employer coverage and Medicaid. Results were extrapolated from a survey of 2,425 adults between the ages of 18 and 64, who responded to the RAND survey in both March 2014 and September 2013.


Reminder: CMS Online Disclosure Due by March 1, 2014

This requirement is nothing new. In the past health plan sponsors have been required to complete an annual online disclosure form with the Centers for Medicare and Medicaid Services (CMS), to show whether the prescription drug coverage offered under the sponsor's plan/plans are "creditable" (at least as good as Medicare Part D's prescription drug benefit) or "noncreditable" (not as good). The plan sponsor must complete the disclosure within 60 days after the beginning of the plan year.

Who Is Exempt From this Process?

As an employer if you do not offer drug coverage to any Medicare-enrolled employee, retiree or dependent at the beginning of the plan year are exempt from filing. Similarly, employers who qualified for the Medicare Part D retiree drug subsidy are exempt from filing with CMS, but only with respect to the individuals and plan options for which they claimed the subsidy. If an employer offers prescription drug coverage to any Medicare-enrolled retirees or dependents not claimed under the subsidy, the employer must complete an online disclosure for plan options covering such individuals.

Filing with CMS  is due by March 1, 2014.

A CMS filing is also required within 30 days of termination of a prescription drug plan and for any change in a plan's creditable coverage status. As described above some plans are exempt from the filing requirement.

Instructions related to the online filing discuss the types of information that are required, including the total number of Part D eligible individuals, the number of prescription drug options and which options are creditable and noncreditable. Click to access the instructions. Please save any documentation of this filing for your records.

Click to access the online portal that is used to complete the submission.