Medicaid expansion could spell trouble for patients

Original article https://www.benefitspro.com

By Kathryn Mayer

Medicaid is poised to expand in a big way — thanks to the Patient Protection and Affordable Care Act — but just who is going to treat those new patients?

That’s the major flaw of Medicaid expansion, according to new analysis from HealthPocket, a website that compares and ranks health plans.

HealthPocket’s research found that physicians across the board report low acceptance rates for Medicaid patients — and physician assistants and nurse practitioners are unlikely to fill the gap, raising the question of whether Medicaid expansion will simply leave more Americans insured but with no one to go to for their care.

Only 43 percent of doctors report that they currently accept Medicaid patients. At the same time, physician assistants and nurse practitioners — viewed by many as a potential solution to the primary care physician shortage — report that only 20 percent of them accept Medicaid.

Results of HealthPocket’s study were based on data from National Provider Identifier registry which included information self-reported by more than 1 million health care providers.

“Ensuring there are sufficient health care providers available to the newly insured — even those with private insurance — is a major public health challenge right now,” Kev Coleman, head of research and data at HealthPocket, said in a statement. “But if the current Medicaid acceptance rates hold true for 2014, timely access to care for those relying on Medicaid is likely to become more difficult as enrollees increase for an already inadequate pool of doctors.”

Historically, Medicaid payments to doctors have been lower than payments from both private insurance and Medicare despite being for the same service. According to the Kaiser Family Foundation, Medicaid pays doctors only 66 percent of the amount Medicare pays for the same service.

PPACA includes provisions to raise reimbursements rates of Medicaid compared to Medicare and other plans, but those have not fully been implemented and offer only a temporary two-year increase.

Previous reports also have found that physicians are hesitant to accept Medicaid patients, but HealthPocket’s survey is different because it also examines Medicaid acceptance rates for PAs and NPs, potentially signaling a greater problem than initially thought.

That’s already on top of a continuing — and growing — doctor shortage. The Association of American Medical Colleges predicts there will be a shortage of 90,000 doctors by 2020, half of whom are primary care physicians. The influx of new patients under PPACA will have profound implications for patient access to medical care, doctor groups have warned.

Many states have been struggling with whether not to expand Medicaid, the government health insurance program for the poor, despite the fact that the federal government will pay the full cost of the new enrollees for three years, and much of the costs thereafter, under health reform. Though the administration had intended for the expansion to be mandatory, the Supreme Court ruled last year that states could opt out, leading many Republican governors to do so.

A recent Gallup report also signaled challenges and costs ahead for an expanded Medicaid program: The research found that Medicaid patients are significantly worse health than those with employer-sponsored coverage.

A third of Medicaid patients are obese, while another 22 percent are being treated for depression and 24 percent are being treated for high blood pressure, according to the latest Gallup-Healthways Well Being Index. Medicaid patients are also more likely suffer from diabetes and asthma.

Some researchers worry that those who most need treatment simply won’t be able to access it.

“No matter if you live in a city with a high or low average income, finding a Medicaid provider is a challenge,” Coleman said. “New Medicaid enrollees are going to have to do some digging to make sure they can find a doctor or another type of practitioner willing to see them and accept these reimbursement rates.”

 


The Affordable Care Act Three Years Post-Enactment

Source: https://www.kff.org

Three years ago, on March 23, 2010, the Affordable Care Act (ACA) was signed into law. Although the date for full implementation of most provisions of the law is January 1, 2014, the ACA has already had an impact on the goals of expanded coverage of the uninsured, improved access and better care delivery models, broader access to community-based long-term care, and more integrated care and financing for beneficiaries who are dually eligible for Medicare and Medicaid. Although the ACA remains controversial, with many debates about its future as well as provisions already implemented, implementation is proceeding.

Much remains to be put in place leading up to 2014. This brief summarizes ACA-related activities to date in terms of tangible benefits and policy changes on the ground with respect to private insurance and Exchanges, Medicaid coverage, access to primary care, preventive care, Medicare, and Medicare and Medicaid dual eligible beneficiaries.

Private Insurance and Exchanges

  • Young adults up to age 26 can stay on their parents’ insurance policies. Young adults can qualify for this coverage even if they are no longer living with a parent, are not a dependent on a parent’s tax return, or are no longer a student. Census data show that over two million young adults have gained coverage, contributing to the decline of 1.3 million in the number of uninsured Americans in 2011.
  • Many states are moving forward with building new health insurance marketplaces. To date, 17 states and the District of Columbia are establishing state-based health insurance exchanges while another seven states will partner with the federal government to run their exchanges. These states are making critical decisions about how insurers will participate in the exchanges, what types and how many plans will be offered, and what types of consumer assistance will be available to help people enroll in coverage. States are also building the IT infrastructure for the exchanges to be ready when open enrollment begins on October 1. In the remaining 26 states, the federal government will operate a federally-facilitated exchange, and residents will get the same benefits and tax subsidies as in states operating their own Exchanges.
  • Coverage exclusions for children with pre-existing conditions were prohibited as of September 23, 2010. Insurers are no longer permitted to deny coverage to children due to their health status, or exclude coverage for pre-existing conditions. Protections for adults will take effect in 2014. In addition, lifetime limits on coverage in private insurance have been eliminated and annual limits are being phased out.
  • Medical loss ratio and rate review requirements are improving value and lowering premium growth for consumers. Medical loss ratio standards require insurers to spend 80-85% of premium dollars on direct medical care instead of on administrative costs, marketing, or profits, or pay rebates back to consumers. Failure to meet these standards has resulted in insurer payments of over $1 billion in rebates to consumers. In addition, expanded review of insurance premium increases by states and the federal government has led to some rate increases requested by insurers being denied, withdrawn, or lowered, which has slowed overall premium growth.
  • All health plans must provide a standardized, easy-to-read Summary of benefits and Coverage (SBC). The SBC gives consumers consistent information about what health plans cover and what limits, exclusions, and cost-sharing apply. It includes illustrations of how coverage works by estimating what a plan would pay and what consumers would be left to pay for common health care needs such as an uncomplicated pregnancy or management of diabetes. Kaiser Family Foundation tracking polls indicate the SBC is one of the most popular provisions in the ACA.

Medicaid coverage

  • More than half the Governors have announced support for the Medicaid expansion. Twenty-seven Governors intend to implement the Medicaid expansion. Another seven are still weighing their options. Seventeen Governors have stated their opposition to the expansion.
  • Seven states have expanded Medicaid to adults since the enactment of the ACA, helping to build on the very limited base of coverage available to low-income adults today. While the enhanced federal funding for the ACA Medicaid expansion to low-income adults does not take effect until January 1, 2014, seven states – CA, CO, CT, DC, MN, NJ, and WA – have used the ACA option to expand Medicaid earlier at their regular match rate, or used Section 1115 waiver authority to do so. Nearly all these states previously covered low-income adults using state-only dollars, but transitioning that coverage to Medicaid enabled them to preserve and, in some cases, expand adult coverage by securing federal matching funds.
  • Medicaid and CHIP have remained primary sources of coverage for low-income children and pregnant women. To help preserve the existing base of coverage in the period leading up to the coverage expansions in 2014, the ACA required states to maintain the Medicaid and CHIP eligibility, enrollment, and renewal policies they had in place when the ACA was enacted. Notwithstanding the recent recession and state budget pressures, eligibility for these programs has remained largely stable, and the programs have remained primary sources of coverage for low-income children and pregnant women. The preservation of Medicaid and CHIP coverage has been important to progress in reducing the number of uninsured Americans – which declined by 1.3 million in 2011.
  • Nearly all states are modernizing and streamlining their Medicaid enrollment systems. Taking advantage of a time-limited 90% federal match rate available for systems development, almost all states are already moving forward with major improvements to their information technology (IT) infrastructure to prepare for the ACA’s new streamlined, coordinated enrollment system. In addition, an increasing number of states – now totaling 37 – have implemented an electronic online application in Medicaid or CHIP, and the number of states with an online renewal process rose from 20 in 2011 to 28 in 2012. Over two-thirds of states now provide online accounts.
  • Ten states have adopted the ACA’s new Medicaid option to provide health homes for those with chronic conditions or serious mental illness. Another five states plan to implement health homes. Health homes are among the ACA’s broader set of initiatives to improve care and better manage spending for people with complex and high-cost needs. Building on patient-centered medical homes, health homes incorporate comprehensive care management, health promotion, transitional care, and other services and supports to provide more integrated, “whole person” care for Medicaid beneficiaries with multiple chronic conditions or a serious and persistent mental illness.
  • States are taking advantage of new and expanded opportunities to provide home and community-based long-term services. Many people with long-term care needs prefer to receive services at home or in the community rather than in institutional settings, and home and community-based services (HCBS) are often less expensive. The ACA expands states’ opportunities to rebalance their long-term care programs toward community-based care and provides new federal funding for this purpose. A total of 46 states, including DC, have received federal grant money to transition Medicaid beneficiaries from institutions back to their homes or community-based settings through the “Money Follows the Person” demonstration program, which the ACA extended. Sixteen of these states first undertook a demonstration this past year. A growing number of states – 25 currently – are responding to other new flexibility and federal financial incentives the ACA provided to increase access to HCBS.

Access to Primary care

  • Primary care providers get increased Medicare and Medicaid payment rates under the ACA. The ACA provides for a 10% bonus payment on top of the regular Medicare fee schedule amount for many primary care services provided by primary care physicians (and other practitioners) from 2011 through 2015. The law also requires states to raise their Medicaid payment rates in 2013 and 2014 to Medicare payment levels for many primary care physician services. As a result, Medicaid primary care fees will increase by 73%, on average, in 2013 although the size of the increase will vary by state. The Medicaid increase is fully federally funded up to the difference between states’ July 1, 2009 fees and Medicare fees in 2013 and 2014.
  • Because of new ACA investments in the health center program, health centers’ patient capacity has expanded. The ACA created a five-year $11 billion Health Center Trust Fund to support health center growth in preparation for the coverage expansion beginning in 2014. Drawing on this fund, health centers are serving an additional 1.5 million patients, and they have been able to maintain their capacity to serve another 2.2 million patients whom they were earlier able to reach only because of a (now-expired) temporary increase in federal funding when the recession was at its deepest. In addition, over 700 health centers received grants for capital improvements from funds provided by the ACA for this purpose.
  • Thousands of new primary care providers have been added to the ranks of the national health Service Corps (nhSC), bolstering the health care workforce in medically under served communities. The ACA provided increased funding of $1.5 billion for the NHSC, which provides loan repayment to medical students and others in exchange for service in low-income under served communities. Health centers, which serve millions of people in these communities, rely heavily on the NHSC to recruit their physicians, dentists, and other health care professionals. As a result of the ACA investment and earlier investments by the American Reinvestment and Recovery Act of 2009, the number of NHSC clinicians is at an all-time high – triple the number in 2008.Today nearly 10,000 NHSC providers are providing primary care to approximately 10.4 million people at nearly 14,000 health care sites in urban, rural, and frontier areas.
  • Additional efforts to expand the primary care workforce are also underway. New training and retention programs have also been created to develop and strengthen the primary care workforce. The ACA has increased the number of graduate medical education residency programs, including establishing 11 Teaching Health Centers to support primary care training in ambulatory care settings. Other efforts include investments in training for nurses and physician assistants, and financial support for nurse-managed clinics.

Access to Preventive Services

  • Preventive benefits with no patient cost-sharing are now required in Medicare and private insurance (except for grandfathered plans). The benefits that must be covered include services found to be effective by the USPSTF, immunizations for adults and children endorsed by the CDC Advisory Committee on Immunization Practices, and pediatric services recommend by HRSA’s Bright Futures for Children. Private plans must cover additional preventive services for women without cost-sharing, including all FDA-approved contraceptive methods (non-profit, religious employers that object to that requirement are exempt) and at least one annual well-woman visit. HHS estimates that, as a result of the ACA, 71 million children and adults with private insurance, and 34 million Medicare beneficiaries have received no-cost preventive care. Enhanced federal matching funds in Medicaid are available to states providing all USPSTF-recommended preventive benefits without cost-sharing, but, to date, few states have made the changes required to gain the higher match rate.
  • The ACA supports population-based prevention activities through a new Prevention and Public health fund. This Fund has been used to make over $1 billion in critical investments in programs aimed at reducing the burden of chronic disease and improving the overall health of communities. Funding has supported Community Transformation Grants in 36 states to reduce the incidence of heart attacks, strokes, cancer, and other diseases; rebuilding the immunization infrastructure; tobacco cessation programs; and substance abuse and suicide prevention activities.

Medicare 

  • Medicare beneficiaries enrolled in Part d drug plans are receiving additional help with their “doughnut hole” prescription drug costs. The ACA required drug manufacturers to offer a 50% discount on brand-name drugs in the coverage gap phase of the Medicare drug benefit, known as the “doughnut hole,” beginning in 2011. It also required Part D plans to offer additional coverage for brand-name and generic drugs for enrollees who reach the coverage gap, and phases out the gap by 2020. In 2013, plans pay for 21% of the cost of generic drugs and 2.5% of the cost of brands, on top of the 50% manufacturer discount. According to HHS, as of March 2013, 6.3 million Medicare beneficiaries have saved over $6.1 billion on prescription drugs in the Medicare Part D doughnut hole since the ACA was enacted.
  • New initiatives testing delivery system and payment reforms are being developed and implemented rapidly around the country, including Accountable Care organizations (ACos) and bundled payments. The ACA established a new Center on Medicare and Medicaid Innovation charged with reducing costs in Medicare, Medicaid, and CHIP while preserving or enhancing quality of care. The Innovation Center develops, tests, and supports new delivery models to increase coordination of care and improve quality, along with new payment systems to encourage more value-based care and move away from fee-for-service payment. For example, the Innovation Center has approved more than 250 ACOs to participate in the Medicare Shared Savings Program in 47 states and territories; these ACOs cover more than four million beneficiaries in traditional Medicare.
  • Medicare savings in the ACA have helped extend the solvency of the Medicare Part A trust fund. The ACA included Medicare savings measures that were projected to reduce growth in Medicare spending over time. The measures included reduced payments to Medicare Advantage plans, smaller updates in payment levels to hospitals and other providers, and increased premiums for higher-income beneficiaries. These changes, along with a payroll tax increase for higher-income taxpayers, contributed to the extended solvency of the Medicare Part A trust fund. Medicare spending per beneficiary is projected to grow more slowly than private health insurance spending per capita over the next decade, and premiums and cost-sharing for many Medicare-covered services are lower than what they would be without the ACA.

Medicare and Medicaid Dual Eligible Beneficiaries


HHS finalizes Medicaid rule

Source: https://www.benefitspro.com

By Kathryn Mayer

Health officials on Friday issued a final rule guaranteeing 100 percent funding for new Medicaid beneficiaries as part of the Patient Protection and Affordable Care Act.

Health reform authorizes states to expand Medicaid to adult Americans under age 65 with income of up to 133 percent of the federal poverty level—about $15,000 for a single adult in 2012—and provides unprecedented federal funding for these states.

Under the new regulations, the federal government will pay all of the cost of certain newly eligible adult Medicaid beneficiaries through 2016, phasing down to a permanent 90 percent matching rate by 2020. It will remain there permanently.

The rule, issued by the U.S. Department of Health and Human Services, will take effect in January of next year.

“This is a great deal for states and great news for Americans,” HHS Secretary Kathleen Sebelius said. “Thanks to the Affordable Care Act, more Americans will have access to health coverage and the federal government will cover a vast majority of the cost. Treating people who don’t have insurance coverage raises health care costs for hospitals, people with insurance, and state budgets.”

HHS said the rule builds on several years of work that the department has done to support and provide flexibility to states’ Medicaid programs ahead of the 2014 expansion. The rule also offers more collaboration with states on audits that track down fraud and outlines ways states can make Medicaid improvements without going through a waiver process, HHS said in comments.

The administration will take comments from interested parties and the public for 60 days. The full text of the rule can be found here.

 


What is my State doing with Exchanges, Medicaid under PPACA?

Source: United Benefit Advisors

States have two major decisions to make with respect to the Patient Protection and Affordable Care Act (PPACA) -- whether they will run the health exchange themselves, and whether they will expand Medicaid to cover most individuals whose income is below 133 percent of the federal poverty level.

Exchange Election

Beginning in 2014, all states will have a health exchange.  If a state chooses not to run an exchange, the federal government will run the exchange for the state. An exchange run by the federal government for a state is called a federally facilitated exchange (FFE). States may also choose to share the operation of an exchange with the federal government - that is called a partnership exchange.

Learn More

Medicaid Election

States also have to decide whether they will expand Medicaid coverage to most individuals who have an income below 133 percent of the federal poverty level (FPL). The FPL is $11,490 for a single person and $23,550 for a family of four in 2013.  The federal government will pay most of the cost of expanded Medicaid coverage, but some states have concerns about the ultimate cost of the expansion to the states.

Learn More 

As of Feb. 1, 2013, the states had made the following choices.  (The deadline for most exchange elections for 2014 has passed, although states may elect a partnership exchange for 2014 until Feb. 15, 2013.  There is no deadline for the Medicaid election.  It is expected that many states will make the Medicaid expansion decision as part of their 2013 budgeting process.)

Click Map to See results for your state


Medicaid Election

Source: United Benefit Advisors

Medicaid is a joint state-federal program. States are not required to participate in Medicaid, but all of the states currently do. The federal government pays 50 percent to 75 percent of the cost of Medicaid. In return, the states must follow a variety of rules, although they have the ability to make a number of choices. Currently, to obtain federal funding the states must provide Medicaid to pregnant women and children under age six with family incomes below 133 percent of FPL, to children aged six through 18 with family incomes below 100 percent of FPL, and to disabled and elderly adults who qualify for Supplemental Security Income based on low income and assets. Some states currently provide Medicaid to working parents and adults without dependents, but many do not, or do so only for those with incomes well below FPL.

In an effort to reduce the number of uninsured, PPACA would require Medicaid to cover virtually all adults with household incomes at or below 133 percent of FPL as of Jan.1, 2014. The federal government would pay 100 percent of the cost of coverage for the expanded coverage group during 2014 through 2016, and then gradually decrease its contribution to 90 percent of the cost for 2020 and later years. The Supreme Court ruled that Congress did not have the power to cut off all Medicaid funding if a state didn’t expand Medicaid to meet the expanded eligibility under PPACA, so states are now deciding whether expanding Medicaid eligibility makes sense for them.

Individuals who are eligible for Medicaid will not be eligible for premium subsidies. This means that employers in states that choose not to increase Medicaid eligibility may have to pay penalties on more employees than those in states that have chosen to expand Medicaid eligibility.

Click Map to See results for your state


The States: Where They Stand

State Type of Exchange Medicaid Expansion
Alabama Federal No
Alaska Federal Undecided
Arizona Federal Yes
Arkansas Partnership Yes
California State Yes
Colorado State Yes
Connecticut State Yes
Delaware Partnership Yes
Florida State Yes
Georgia Federal Undecided
Hawaii Federal No
Idaho State Yes
Illinois State No
Indiana Federal Undecided
Iowa Partnership Undecided
Kansas Federal Undecided
Kentucky State Undecided
Louisiana Federal No
Maine Federal No
Maryland State Yes
Massachusetts State Yes
Michigan Partnership Undecided
Minnesota State Yes
Mississippi Federal No
Missouri Federal Yes
Montana Federal Yes
Nebraska Federal Undecided
Nevada State Yes
New Hampshire Federal Undecided
New Jersey Federal Undecided
New Mexico State Yes
New York State Undecided
North Carolina Federal No
North Dakota Federal Undecided
Ohio Federal Yes
Oklahoma Federal No
Oregon State Undecided
Pennsylvania Federal Undecided
Rhode Island State Yes
South Carolina Federal No
South Dakota Federal No
Tennessee Federal Undecided
Texas Federal No
Utah State Undecided
Vermont State Yes
Virginia Federal Undecided
Washington State Yes
West Virginia Partnership Undecided
Wisconsin Federal Undecided
Wyoming Federal Undecided

 

Source for exchange elections: Kaiser Family Foundation

Source for Medicaid expansion: The Advisory Board Co.