Recently in CMS Category

It used to be that late August in Washington, D.C. was the perfect time to clean the junk out of your office, delete old emails, and go to the dentist. Now, though, the high energy folks in the Obama Administration charged with implementing health reform are bringing yet more change to Washington, D.C..  Yesterday, they sponsored an all-day listening session with stakeholders to gather thoughts and insights on the new Exchanges that are so central to health reform.  They brought together employers, labor leaders, consumer advocates, insurers, and a host of other experts to cover exchange issues such as how to communicate with consumers; small businesses and exchanges; governance issues; promoting delivery system reform; and the role of exchanges in determining eligibility for premium and cost-sharing subsidies and coordinating with Medicaid.

The discussion was incredibly rich, but one theme that emerged over the course of the day - and that also was very much in keeping with HHS's vision for the meeting - is the importance of securing consumer input into health reform implementation and using a transparent decision-making process.  Glen Schor with the Massachusetts' Connector was particularly eloquent on this point, calling transparency a "hallmark" of how Massachusetts has succeeded in implementing health reform.  He and others noted it can be time consuming and cumbersome to solicit consumer input and to share all sorts of details about policymaking, but it is ultimately vital to helping people feel comfortable with major changes.

From a consumer perspective, there also was a fascinating discussion about the kinds of information that people will need to make decisions about their health care coverage under reform.  Of particular note, I thought, were comments by DeAnn Friedholm of Consumers Union about the importance of recognizing that people make decisions in different ways.  Drawing on Consumers Union's experience with publishing Consumer Reports, she pointed out that not everyone is likely to want a detailed chart comparing a health plan along a zillion different dimensions.  Instead, some people may want a much simpler set of information, such as three good health plan options from which they can choose.   While I personally am a huge fan of multi-dimensional charts and love a good spreadsheet, I'm guessing that much of America will want dramatically simplified information about how to secure coverage and enroll in subsidies.

I participated in a panel headed by Director of the Center for Medicaid and State Operations Cindy Mann on coordinating Medicaid and Exchange coverage.  Many of the ideas will be deeply familiar to long-time Medicaid and CHIP experts and advocates, including the need for unified and simplified application and retention procedures for Medicaid and the Exchange; the importance of building a strong information technology infrastructure for eligibility determinations that allows linkages between the Exchanges, Medicaid and CHIP and databases that can be used to verify eligibility; and the value of providing people with multiple ways to apply for (renew) coverage, such as the option to submit applications on-line and/or to secure help from a community-based organization.  At the same time, we discussed that the tax credits for premium assistance and cost-sharing subsidies pose some unprecedented challenges, including that the tax system is based on annualized income and is not designed to respond when incomes fluctuate over the course of a year. 

As intended, the day raised more questions than answers, but, all-in-all, was much better than a trip to the dentist.  Seriously, it was impressive to the extent to which people are beginning to roll up their sleeves and work on turning the health reform law into a practical reality.

Health care "exchanges" are critical to fulfilling the promise of the Affordable Care Act and how states decide to meet their responsibility to establish them will have an enormous impact on children and families.  Today, the Department of Health and Human Services is hosting a stakeholder conference to discuss exchanges. To coincide with the conference, my colleagues, Dawn Horner and Sabrina Corlette, released an issue brief that takes a deeper look at exchanges and what's at stake for children and families. 

HHS's day-long conference is intended to engage stakeholders on the important policy decisions surrounding the establishment and operation of exchanges.  CCF's Jocelyn Guyer will take part in a panel discussion and Dawn Horner will attend the conference. (You can view the conference via be webcast here.)

We'll hear more from them about the conference tomorrow, so let's get back to the issue brief.  "Health Exchanges: New Coverage Options for Children and Families" provides a comprehensive overview of exchanges and key questions policymakers must consider when establishing exchanges.  It outlines the funding and design decisions the states will have to make fairly quickly and points out the broad responsibilities exchanges will have in ensuring that consumers can make informed health care coverage choices.  

For example, the Affordable Care Act requires plans to offer child-only policies (reflecting the importance policymakers placed on the need to ensure that children could secure coverage even if their parents were ineligible for an exchange plan).  Beyond the essential benefits packages, exchange plans must provide children with a comprehensive package of preventive care services (referred to as Bright Futures), including immunizations, well-child visits, vision and hearing tests, health and behavioral assessments, and developmental screenings, with no cost-sharing.  These federal standards are only a floor and states can require plans to cover services for adults and children that are not in the minimum package.  In fact, a number of states already have policies mandating that plans cover specific services, some of them critical to children. (Sixteen states and the District of Columbia mandate that insurers offer at least some level of services for autism.)

Another issue that could impact many families is how well states meet the "no wrong door" policy established by the new law.  It is vital that exchanges coordinate closely with Medicaid and CHIP because many people will move back and forth between subsidized exchange coverage and public program eligibility as their income fluctuates.  The brief points out that states should consider ensuring that some plans offered in the exchange also serve Medicaid and CHIP beneficiaries, creating overlapping provider networks and requiring plans to help facilitate transitions for those in the middle of treatment.

The brief also covers the importance of dynamic technology applications to the success of the exchanges.  The exchange procedures envisioned under the ACA rely heavily on the application of smart technology systems. States should consider setting up a working group now to begin to build these systems. As a first step, a state can pave the way toward electronic interfaces by implementing the proven Medicaid and CHIP automated linkage with the Social Security Administration allowed under CHIPRA to verify citizenship status.

These are but a few of the insights included in the issue brief.  I hope you'll take the time to read it for yourself and share it with others in your state.  We would also love to hear from you on how your state is approaching the establishment of its exchange.

For all those wondering what was going on with the 2010 federal poverty level, your answer arrived today in the Federal Register. But while I have your attention, here's the back-story.

A decline in the average CPI-U during 2009 would have required HHS to issue poverty guidelines in 2010 that were actually lower than those in 2009, leading to a reduction in eligibility for the safety net programs that rely on the guidelines, including Medicaid. (This would have been an unprecedented event - the only reduction since the issuance of the first poverty guidelines in 1965).

In December, the Department of Defense Appropriations Act (go figure) included a provision to freeze the poverty guidelines at 2009 levels through March 1, 2010. This freeze has been extended twice more until at least May 31, 2010. (I say at least, because all three extensions included language stipulating that the poverty levels would remain in place until updated guidelines were published, hence the somewhat fungible deadlines).

I don't know about you, but I've been on pins and needles since the end of May waiting for the publication of the updated guidelines. Well, the wait is over... ASPE modified the procedure for updating the guidelines to take into account the changes in the CPI-U during the freeze. (Typically, ASPE uses price changes through the most recent "completed" year. In this case, they also took into account the changes between January 2009 and May 31, 2010.) 

The percentage increase in the CPI-U was so small that as a result, the poverty guideline figures for the remainder of 2010 are unchanged from the 2009 poverty guideline figures. These guidelines will remain in effect until ASPE publishes the 2011 guidelines, which are expected in late January 2011.

Summer vacation is not even half over and I'm already thinking about getting my kids ready to go back-to school.  It's not that I don't enjoy their company; I just want to get a jump-start on my to-do list so that I deliver them to school ready to learn.  Along with back-to-school shopping, they need their annual physicals and 6-month dental check-ups.  Child health advocates around the country have another major item on their back-to-school checklists - reaching out to the five million children who are eligible for Medicaid or CHIP but are unenrolled. 

This is an ideal time of year as the media and huge segments of our population are focused on children's needs as they prepare to head back to school. The National Covering Kids and Families Network (NCKFN) is helping groups leverage the increased attention to children's issues during the back-to-school period to help reach enroll eligible children in state Medicaid and Children's Health Insurance Program plans. They recently hosted a webinar to discuss messaging and strategies that work. (Georgetown CCF is providing technical assistance to NCKFN). 

Many of the NCKFN participants and other groups have been working on back-to-school efforts for many years and had a wealth of experience to share with each other. Some excellent messages have been developed for groups working on this initiative by GMMB with the support of the Robert Wood Johnson Foundation.  The trick is getting the right messengers to use the messages to reach families of uninsured children. Many of the NCKFN groups have had a lot of success working with school nurses, school administrators, social workers, community outreach workers and teachers. Two participants on the webinar focused on more non-traditional messengers - school board members and youth sport leaders. 

First, Donna Cohen Ross, senior advisor to the Office of External Affairs at CMS (and an expert on outreach), announced HHS's plan to launch a coaches campaign "Get Covered: Get in the Game" which will enlist youth sports leaders to help find uninsured children and get them enrolled (more details on the campaign to come in August). Coaches are great messengers.  (Just compare the sports section to the health section of your local newspaper if you doubt the ability of sports leaders to get a message across in your community.)  Coaches can pitch a different message to families by linking the importance of coverage with the ability to compete in team sports. As Donna pointed out, there is a strong link between good health care and sports as kids frequently are excluded from school sports participation if they don't have a physical.  Parents are also understandably reluctant to allow children to participate in sports if they aren't insured for fear of an injury that they can't afford to treat. 

As the mother of three boys, I'm involved with my fair share of youth sports teams and recall one heart-breaking incident when one of my son's soccer teammates suffered a concussion during a tournament.  I offered to drive him and his mother to the hospital but she said she didn't have insurance so she would just wait to see if he really needed care.  No mother should be faced with that choice and coaches could help make sure they are not.  Good coaches teach children more than just about sports, they teach them about the importance of teamwork, perseverance, and hard work and they make sure kids are doing as well off the field as they are doing on the field.   Youth sports participation helps children learn many valuable life lessons and it is tragic that some children are unable to fully participate in this aspect of childhood due to the lack of insurance coverage - especially for those who are eligible but unenrolled in CHIP or Medicaid. 

Second, April Griffin, a school board member from Hillsborough School District in Florida, spoke about the importance of getting buy-in at the top. (In other words - cultivating the grass tops as well as the grass-roots).   She pointed out that school district staff and teachers are stretched thin and are under pressure to raise test scores.  According to Ms. Griffin, the more groups are able to link children's health coverage with school performance, the more successful they should be in getting the buy-in of school system personnel. 

Her message also hit home.  A friend of mine tried to get our school district to include information about our state's Medicaid and CHIP programs in back-to-school packets.  The school district staff refused and said it was against school district policy.  My friend appealed to a school board member by pointing out that the school district included promotional materials of for-profit insurance companies in the packets.   The school board member was able to look at the "big picture" rather than reading a policy manual and gave the staff person the go-ahead to include the CHIP & Medicaid information in this fall's packets. 

There were a lot more great ideas shared on the NCKFN webinar and I encourage readers to check them out here.  In collaboration with the network, Donna Cohen Ross of CMS has scheduled a second webinar on school-based outreach efforts on July 29th. (All those of you who have read Donna's posts on this blog or have worked with her over the years know that Donna cares deeply about this topic and you won't want to miss this opportunity.)   

By Judith S. Palfrey, MD, FAAP

President, American Academy of Pediatrics

On Wednesday, I was honored to attend an event in DC unveiling the US Department of Health and Human Services' (HHS) Interim Final Rule on preventive services under health reform. To so many of us in the business of taking care of children, the achievement of passing the law last March was a time of historic celebration, and now, as one of the most significant pieces of the law takes shape, we realize just how much better off our children will be under health reform.

One of the earliest provisions of the Patient Protection and Affordable Care Act to take effect is Section 2713, which requires health plans to cover, at absolutely no out-of-pocket cost to families, preventive care services outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Supported by the Health Resources and Services Administration, Bright Futures is the definitive standard of pediatric well-child and preventive care developed by an evidence-informed, active collaboration led by the American Academy of Pediatrics (AAP).

Perhaps the best-known aspect of Bright Futures is the schedule of "well-baby and well-child visits" it establishes--31 visits between birth and age 21 years (to pediatricians and other clinicians, it is also known as the "periodicity schedule"). The interim rule clearly states that all components of pediatric well-child visits--including physical exams, immunizations, hearing and vision screening, developmental and behavioral screening, and anticipatory guidance--in accordance with the Bright Futures periodicity schedule must be free of financial barriers, including co-pays and deductibles. Insurers may not exclude any of these services from coverage, and cost-sharing cannot be imposed on families.

This landmark investment in preventive services will eventually allow all families, regardless of income, the opportunity to visit their pediatrician regularly during their children's most critical years of development. Having coverage for the clinically appropriate well-child visits will allow pediatricians to identify and treat health problems in children before they start. This, in turn, should help bring down the prevalence of chronic conditions that place significant financial and physical strain on children and families.

The Academy will continue to work with HHS on the development of a Final Rule, and in the process, will continue to advocate for the following: all plans--including those retaining "grandfather status"--to cover Bright Futures services; Bright Futures to be appropriately integrated into other initiatives and standards, such as meaningful use and quality measures; and for insurance companies to eliminate cost-sharing while making up those dollars for pediatricians and other health care providers.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Editor's Note:  CCF's Dawn Horner also blogged about the preventive health services rule. 

Doctor Donald M. Berwick, a respected Harvard professor and pediatrician who has built a reputation for improving quality and reducing health care costs, was sworn in this week as administrator of the Centers for Medicare & Medicaid Services.  The agency had been without a permanent administrator since 2006. 

Dr. Berwick was installed in the CMS position through a recess appointment, allowing him to serve without Senate confirmation through the end of 2011.  While he's coming into office under less than ideal circumstances due to the controversy surrounding the recess appointment, a prolonged confirmation process would have delayed filling a crucial job vacancy. CMS has been without a leader for four years and it's important to have someone of his stature at the helm while CMS navigates its way forward toward full implementation of the Affordable Care Act. 

At CCF, we're happy to see the first pediatrician be appointed to head the agency.  With his strong background in children's health care issues, we are hopeful that he'll be influential in recognizing the unique developmental and health needs of children and that his grasp of these issues will be reflected in the policy decisions the agency makes.  

One of the many questions I have asked myself since passage of the Patient Protection and Affordable Care Act is what the role of Section 1115  waivers will be come 2014 when the major provisions of PPACA are implemented. In the past, Section 1115 waivers have sometimes been used to expand coverage to groups previously not eligible for Medicaid (think childless adults) and/or to change the delivery system and benefits package (usually limits that Medicaid doesn't allow). The state of Utah, for example, is using a Section 1115 waiver to establish its Primary Care Network or "PCN" program which offers a very limited benefits package (no inpatient or specialist care) to childless adults and parents not otherwise eligible for Medicaid. States also used CHIP waivers to cover parents and other adults with extra CHIP funds, but Congress shut that down when CHIPRA was reauthorized. In general, the federal Secretary of Health and Human Services has broad discretion to waive provisions of the Medicaid law, although how broad that discretion is has been a matter of dispute.

PPACA does not change the provisions of Section 1115 (with a few notable exceptions I will talk about it in a minute) so states will still have the option to come in and request that many provisions of the Medicaid law be waived. But will they do so given the new environment in 2014 when states must cover all adults below 133%FPL, will receive a very favorable matching rate to do so  and will have new flexibility with respect to the benefits package?  Will states that are currently expressing resistance to features of the new law look to waivers as a way to get around them??? That is a key question which it is hard to predict the answer to.

One option states looking for flexibility in the new world may consider, but that is not a waiver, was included in the bill by Sen. Cantwell (D-WA) and developed to accommodate the continuation of a program like the state of Washington's Basic Health Plan. These provisions are found in Section 1331 of the new law and allow states to receive 95% of the federal premium tax credits that would have flowed to eligible individuals in their state between 133-200%FPL and who are not eligible for Medicaid. States must then contract with more than one plan to offer a benefits package that is at least good as the essential health benefits package offered in the exchange and with cost-sharing that is no higher than cost-sharing required under a "platinum" plan (for people under 150%FPL) and no higher than cost-sharing in a "gold" plan for people between 150-200% FPL. Since states are subject to a maintenance of effort requirement for children until 2019, this option would only apply to adults in most states where kids today are covered at 200%FPL or above. But one question is whether a state might seek a waiver of that provision to allow families to be covered together through a Basic Health program such as that contemplated by Section 1331 of PPACA. This might have some benefits such as covering families together and possibly charging a higher percentage of the costs to the feds. However important questions would have to be examined on the benefits and cost-sharing side to make sure that kids still had comparable coverage.

Another new feature of PPACA is Section 1332, which establishes a new Waiver for State Innovation. This provision, championed by Sen. Wyden (D-OR) does establish new waiver authority that is broader than Section 1115 authority and would allow states to waive the provisions of the new law related to exchanges, benefits and cost-sharing protections A state could apply for this new waiver through a new coordinated process with a Section 1115 Medicaid and/or CHIP waiver. Coverage provided must be at least as comprehensive and cost-sharing must be at least as affordable as it would have been under the exchanges.

This new waiver awaits more detail in guidance, but one critical note is that it is not a tool available to states until plan years beginning January 1, 2017. So this will not be an option for states to bypass the main features of health reform before it even gets started.

Much of the current waiver activity is about renewing existing waivers (typically three years which will bring some states right to 2014) and/or extending managed care to people with disabilities. But please let us know if you hear about any new major waiver ideas your state is contemplating. This one bears watching.

Tune in for Part 2 which will focus on the new rules we are expecting on public participation in the waiver process.

Last week, CMS issued a final rule on the premiums and cost-sharing that states can charge Medicaid and CHIP beneficiaries in light of the Deficit Reduction Act of 2005  and cost-sharing provisions relating to Native Americans included in the American Recovery and Reinvestment Act of 2009.  This rule has been kicking around for quite a while - it was first issued by the Bush Administration in November of 2008 and since then has been subject to a number of revisions and delays.  Within the confines of what is allowed under the DRA and Recovery Act, the latest changes are explicitly aimed at better protecting low-income people from premiums and cost-sharing charges that could adversely affect their access to care.  Some of the most notable improvements include: 

• No more "shoebox" method.  Under the final rule, states (not families) are responsible for tracking and making sure that cost-sharing charges (including premiums) faced by low-income beneficiaries do not consume more than 5 percent of their income.  This means states can't use the "shoebox" method for tracking cost-sharing charges.  Under this method, families were expected to keep track of their cost-sharing and premium payments, keep a running tab on their cumulative total, and calculate the point at which their payments for cost-sharing begin to consume more than 5 percent of their income.  Now, states will need to figure out how to track and inform families about when they hit the five percent limit.  Alternatively, states can design cost-sharing and premium charges in such a way that families are never at risk of hitting the five percent limit.
• Stronger public input.  The final rule requires states to document that they have given the public advance notice about major changes in cost-sharing rules, and given people the opportunity to provide input in accordance with state rules.
•  Clearer protection of preventive care for children.  The final rule specifies that, for children under 18, all well baby and well child care and immunizations described by the American Academy of Pediatrics in its Bright Futures guidelines must be exempt from cost-sharing (as is required more broadly under the health reform law.)
•  New limits on cost sharing and premiums for Native Americans.  As required by the Recovery Act, the final rule outlines that Native Americans are exempt from premiums and cost-sharing charges if they secure care (or are eligible to secure care) from an Indian Health Provider.  Also, the cost of protecting Native Americans from the cost-sharing charges cannot be passed along to Indian health care providers in the form of reduced payments for providing services. 
• Other changes.  Some of the other changes include: 1) reduces the maximum co-payment that can be imposed on kids in CHIP-financed Medicaid expansions who are in managed care from $5.70 to $3.40 per visit in fiscal year 2009 (indexed in future years); 2) Clarifying that family planning services exempt from cost-sharing charges includes contraceptives and other pharmaceuticals; 3) Requires states to describe how they will alert providers when a service is subject to cost-sharing for an individual beneficiary and if that service can be denied for failure to pay the charge; and 4) Requiring states to describe how they will modify a family's aggregate limit on premiums and cost-sharing set at 5 percent of income when they experience a reduction in income.

Finally, it turns out that the final rule is not entirely final in the sense that CMS is still taking comments on provisions that exempt Native Americans from premiums and cost-sharing under certain circumstances.  This is because, unlike the DRA provisions, the language relating to Native Americans is relatively new, having been passed as part of the Recovery Act in February of 2009.

It was a great victory for children and families when Congress included a maintenance of effort (MOE) requirement in health reform so states wouldn't cutback on Medicaid and CHIP coverage before affordable coverage was available through the state Exchanges.  Now, as with so many issues in health care reform, the way it works out for children and their families will depend on how these provisions are interpreted by policymakers in Washington, D.C. and implemented by states. 

Fortunately, the House and Senate leadership and key health reform negotiators are keeping a close eye on the situation.  This week, they stepped forward to urge Secretary Sebelius to issue MOE guidance that will make it clear to states that they cannot set up new enrollment caps or freezes in their Children's Health Insurance program (CHIP), making it harder for eligible uninsured children to secure coverage.  Specifically, they point out in a new letter to the Secretary that the law prohibits "the implementation of enrollment caps and freezes or other restrictive eligibility procedures that were not already in place and operational as of March 23, 2010". 

The letter was signed by Speaker Pelosi, Senate Majority Leader Reid, Senate Finance Chairman Baucus, House Energy and Commerce Chairman Waxman, Senate Health Care Subcommittee Chairman Rockefeller and House Health Subcommittee Chairman Pallone.  They wrote:  "Working together, we are confident that we can continue the nation's successful track record of covering low-income children even as we move forward on a parallel track to implement broader reform that covers millions of Americans for the first time." 

I agree with that sentiment, don't you?