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States Work to Improve Care for Children with Special Health Needs with Quality Measurement
Improving the quality of care that children and youth with special health care needs (CYSHCN) receive is a growing priority for state Medicaid programs. However, many quality improvement efforts are in their infancy as states work to overcome the challenges of measuring and assessing care quality for this vulnerable population. NASHP, with support from the Lucile Packard Foundation for Children’s Health, convened a national work group recently to identify gaps and opportunities in measuring care and designing quality improvement initiatives. This issue brief and case studies from Michigan, New York, and Texas, examine strategies that states can use to advance quality measurement and improvement for CYSHCN.
Proposed Rules Give States Flexibility to Change Essential Health Benefits, and More
The US Department of Health and Human Services (HHS) recently released proposed changes in its annual the rule that governs standards for issuers and the health insurance marketplaces. The annual notice is one of the most significant tools the Administration wields in shaping the health insurance markets and this proposed notice carries significant implications for markets and states.
Below, the National Academy for State Health Policy (NASHP) reviews the changes that will have the greatest impact on state policymakers and consumers. Comments responding to the notice are due to HHS by Nov. 27, 2017.
What states need to know about proposed changes to insurance plan design and oversight:
- Grants greater flexibility to states to set benchmarks for their essential health benefits (EHB).
- It allows states to adopt EHB benchmarks of another state, either in their entirety or for any of the 10 EHB categories defined in the Affordable Care Act (ACA).
- It also redefines the definition of “typical employer plan” by which benchmarks are set, as a small group, large group, or self-insured group plan that has an enrollment of at least 5,000 enrollees.
- Additionally, it mandates that a state’s benchmark must provide an “appropriate balance of coverage” across the EHB categories and allows issuers to substitute benefits between and within benefit categories.
- The notice suggests HHS may establish a federal default definition for EHB in the future.
- Increases a state’s responsibility to perform plan certification and oversight.
- In states that use the federally-facilitated marketplace (FFM), the proposed plan would continue to allow states to conduct network adequacy review and data review for QHP certification.
- It would allow states to maintain oversight over accreditation, compliance reviews, compliance with geographic area standards, and reporting on quality improvement strategies. States operating state-based marketplaces (SBMs) already maintain this authority.
- Facilitates ability to change the medical-loss ratio (MLR) in states.
- Streamlines the processes that enable states and HHS to reduce the MLR from the current threshold that requires that 80 percent of premium dollars get spent on medical services or quality improvement efforts.
- Sets an automatic calculation that 8 percent of spending be counted toward quality improvement for the purposes of MLR calculation.
- Eliminates certain plan standards.
- It eliminates actuarial value requirements in place for stand-alone dental plans offered on the exchanges.
- It eliminates the requirement that an issuer’s offerings must be “meaningfully different” from each other in order to be offered through a marketplace.
- It eliminates standard plan design (also known as simple choice options) on the FFM.
- Redefines certain Children’s Health Insurance Program (CHIP) coverage.
- It proposes to include CHIP buy-in coverage as minimum essential coverage.
- It would allow mothers who lose CHIP coverage obtained during pregnancy to qualify for a special enrollment period (SEP). (CHIP coverage is considered to cover the child, so would not normally qualify the mother for a SEP triggered by loss of coverage)
Proposed changes to rate review and filing standards:
- It increases the rate review threshold, and streamlines the rate review process. The proposal would raise the threshold at which a reasonable increase review is triggered from 10 percent to a 15 percent, limiting the plans that would require submission of justification for rate increases. States may submit a proposal to increase the threshold. It continues to allow states to evaluate rate increase outliers and may eliminate CMS rate review that is duplicative of states’ processes. It also eliminates requirement to publish state thresholds publicly, and exempts student health plans from rate review.
- It increases state flexibility on rate filing and posting deadlines. The proposal reduces advance notice states must provide to CMS prior to posting rates from 30 to 5 days, and permits states with effective rate review programs to post rates on a rolling bases and to set different rate submission deadlines for QHP and non-QHP products.
Proposed changes to eligibility and verification processes:
- It eliminates self-attestation of income for individuals. It would require a data match for any consumer between 100 to 400 percent of the federal poverty level (FPL) who reports a higher income level than federal data may indicate. Currently, marketplaces can accept self-attestation for any individual who reports a higher income than is indicated by federal data.
- It enables denial of tax credits due to failure to reconcile. It eliminates noticing requirements that prohibited marketplaces from issuing tax credit denials to consumers that may not have reconciled discrepancies in their tax information filed during previous years.
Proposed changes to enrollment programs:
- It streamlines requirements for Navigator programs. It eliminates the requirement that marketplaces include at least two Navigator entities, and that at least one of these includes a community and consumer-focused nonprofit group. It also mandates that Navigators maintain a physical presence in the exchange service area it serve, and seeks comment on accessibility requirements currently in effect for Navigators and assisters.
Proposed changes to the Small-Business Health Options Program (SHOP)
- It eliminates operational requirements for SHOP. It would no longer require SHOPs to perform premium aggregation, online enrollment, and employee-specific eligibility functions. Participating employers would be responsible for collecting relevant information and premiums from employees to send to issuers. Changes will be implemented on the federal SHOP as soon as Jan. 1, 2018. States operating their own SHOP may maintain currently mandated operations.
- It imposes new requirements and grants new flexibility on SHOP issuers. Issuers would be required to maintain greater responsibility to facilitate enrollment in SHOP plans. It allows issuers to base premiums based on enrollee averages, and permits issuers to restrict SHOP annual enrollment periods. Issuers would have broadened ability to apply group participation rules to SHOP plans such as rating standards, and notification and termination requirements.
Beyond these proposed programmatic changes, the notice also invites state officials to comment on several areas where the Administration may provide greater flexibility or guidance in the future. These include:
- How HHS can support the ability of SBMs to leverage commercial platforms;
- How HHS can make the SBM-FP model, by which states operate as an SBM but leverage technology from healthcare.gov, more attractive to states; and
- How HHS can foster insurance innovation and reform including value-based coverage, cost-effective drug tiering (pricing by drug category), innovative network design, person-centered coverage, high-deductible health plans paired with health savings accounts, and policies that promote use of preventive care and wellness.
In the coming weeks, NASHP will continue to analyze how the proposals may impact states and their insurance markets and track state responses to the rule as they rapidly approach the comment deadline on Nov. 27, 2017.
The Administration Ends CSR Subsidy Payments — What Comes Next?
On Friday, Oct. 13, 2017,the Trump Administration announced it would no longer make cost-sharing reduction (CSR) payments to insurers offering coverage on health insurance marketplaces. The announcement cited guidance from the US Department Justice that questioned the legality of the appropriation for these payments (for more Cost Sharing Reduction Debate: Why This Matters and How States Are Preparing for an Uncertain Future).
How It Impacts the 2017 Insurance Marketplace
The Affordable Care Act (ACA) requires insurers to offer CSR subsidies to individuals earning between 100 to 250 percent of the federal poverty level (up to $29,700 income for an individual or $60,750 for a family of four) who purchase plans on the marketplace. In 2017, approximately 7 million individuals — 58 percent of all marketplace consumers — received CSR subsidies. Long-standing consumer protection policies restrict the ability of insurance issuers to adjust rates or withdraw from markets mid-year, so issuers have few options but to fully absorb the costs of CSR subsidies paid on behalf of enrollees for the remainder of 2017.
What This Means for States and Insurers in 2018
Open enrollment for 2018 begins Nov, 1, 2017. On that date, rates and health plan offerings must be set so consumers have accurate information about their insurance plan choices. Insurers in most states were required to submit final rates for 2018 plans by Sept. 27, 2017, before the Administration issued its decision to stop CSR payments (See: Explore the Limited Choices States Face as Washington Debates CSR Payments). To date, most states and insurers chose to submit rates with CSR costs “loaded,” meaning their premium prices assumed the loss of federal CSR payments.
States and issuers that opted to “CSR load” have reported premium increases ranging from 6 percent (Colorado) to 20 percent (Idaho) on top of normal rate increases to account for CSR losses. Increased premiums will lead to a commensurate increase in tax credits to consumers as the tax credits are based on premium costs for silver-level health plans sold on the marketplace. As a result, consumers earning between 100 to 400 percent of the federal poverty level who qualify for the credits will largely be shielded from the premium increases because of the increase in tax credits.
Those most affected will be individuals and families making over 400 percent of the federal poverty level ($47,550 per year for an individual or $97,200 for a family of four), who do not qualify for tax credits and will now bear the full costs of these premium increases.
Insurers in at least 11 states did not originally set rates that included the “CSR load” (Alaska, Colorado, Georgia, Maryland, Massachusetts, Montana, North Dakota, Oregon, South Dakota, Vermont, and Washington). Because they own and operate their own technology, states that operate state-based marketplaces (Colorado, Maryland, Massachusetts, Vermont, Washington) have greater flexibility to adjust rates as deemed appropriate by state regulators, insurers, and marketplace operators. The remaining states utilize the federally-facilitated marketplace (FFM), which is operated by the Centers for Medicare & Medicaid Services (CMS). These states will be limited in their ability to issue changes, pending guidance from CMS. Some, including Alaska and Oregon, have signaled they will immediately adjust rates to account for CSR payment loss. With open enrollment set to begin, these states and insurers must rapidly pivot if they wish to make adjustments prior to the Nov. 1, 2017, sign-up date.
Prior to the Administration’s announcement, several insurers had announced their decisions to exit markets, citing growing costs and market uncertainty spurred by the Administration’s lack of clarity over CSR payments and enforcement of the individual mandate. To date, no additional insurer has announced its intent to exit an insurance market as a result of the Administration’s CSR decision. However, a provision in the 2018 contract for issuers offering through the FFM allows some latitude for these insurers to exit due to CSR funding issues.
Congress and States Take Action
The Administration’s decision may revive Congressional efforts to assure, at least temporarily, payment of CSR subsidies. This was one area of near universal agreement during recent bipartisan hearings on market stabilization held by the Senate Health, Education, Labor, and Pensions (HELP) Committee in September. Following these hearings, Sens. Lamar Alexander (TN) and Patty Murray (WA) have been working on a stabilization bill that is likely to include these payments. Sen. Ron Johnson (WI) has also expressed that he will propose language to fund CSR payments, while proposing other insurance market reforms such as additional flexibility for short-term plans and use of health savings accounts. However, even if a bill is passed, it is uncertain whether the President would sign a bill that is construed as bolstering insurance markets regulated by the ACA.
Meanwhile, 18 states and Washington, DC have filed a lawsuit against the Administration’s decision to discontinue CSR payments. It is possible that, while the case is pending, courts will require the Administration to continue to make CSR payments, drawing out the uncertainty of the issue until the legal case is resolved.
Regardless of future actions, states and consumer groups are actively preparing for the open enrollment season, including launching outreach efforts to lessen consumer confusion spurred by ongoing uncertainty over national health reform efforts. NASHP will continue to monitor their efforts and report as the open enrollment season approaches.
Increasing Urgency for States on Congressional Action for CHIP
We are five weeks away from September 30th, the date current federal funding for the Children’s Health Insurance Program (CHIP) is set to end. Although states can use some of the unspent federal funds that were previously allocated to them, it is projected that those funds will be exhausted during the next fiscal year, beginning as soon as December 2017 for several states. As a result, there is mounting pressure on states to make decisions and take action regarding the operation of their CHIP programs.
Nearly all states have already finalized their FY2018 budgets, and the majority of them have assumed that funding for CHIP will be extended and will include the 23 percentage point federal match increase that is in current federal law. If federal CHIP funding is not extended soon states will need to set up processes for shutting down their separate CHIP programs. If funding is extended without the 23 percent bump, CHIP/Medicaid agencies along with state budget officers will need to assess the magnitude of their state’s funding shortfalls and determine the cost of maintaining coverage for children. For many states, involving the Governor or even convening a special legislative session may be necessary to move forward to establish policy and system changes or to allocate new funding to address the loss of the 23% bump, which would be costly.
Additionally, a growing number of state CHIP officials have reported to NASHP that they are further analyzing their state’s remaining federal CHIP funds. They are starting with the Medicaid and CHIP Payment and Access Commission’s (MACPAC’s) projections of when states will exhaust their federal CHIP funding, which assume all funds will be spent on covering services for enrollees. However, if Congress doesn’t extend federal funding soon, states will need to initiate contingency plans and there are costs associated with making programmatic changes. States assumed federal funding would continue for CHIP, so there are no funds allocated in state budgets to shut down their CHIP programs. As a result, states will need to use their remaining federal CHIP funds to help absorb those costs. It is hard to calculate exactly what those costs will be, but states will need to:
- Invest staff time and financial resources to develop communication plans, including notices to the public about program changes;
- Train call center staff to communicate with families;
- Review and in some cases terminate or change contracts with third party administrators or health plans;
- Make enrollment and eligibility systems changes, which are very costly;
- Develop a transition process, which may include starting with an enrollment freeze or disenrollment and transferring accounts to the Exchange;
- Submit waivers or state plan amendments to CMS; and
- Review and change state law and regulations.
States will also need to reserve a portion of their current CHIP funding to cover claims from fee-for-service medical providers as they have months (in some states up to a year) to file their claims after service is rendered. The amount of funds a state will need to withhold for future claims varies depending upon their service delivery structure, but it is a factor many states will need to consider.
Most importantly, the projections are made using data from previous months’ expenditures, which is the best information states have. But they are just projections. There are factors that could result in states spending more for their CHIP programs in the coming months that are not captured in the current projections. Such factors include increased enrollment as a result of stakeholders’ ‘back to school’ outreach and enrollment campaigns or unanticipated high costs or increased utilization of medical services.
And finally, there is language in some state statutes that requires federal participation to continue operating some portions or all of their state CHIP programs. So, in addition to weighing fiscal concerns, state officials are actively reviewing their own statutes to decide how soon they may have to initiate changes to CHIP. For instance, Colorado has already provided information to the public on their website about the current status of federal CHIP funding and explains that the enrollment in the state’s CHIP program may be affected if federal funding is not extended.
Many state officials have shared that to thoughtfully close their CHIP programs, they would have already begun to make changes and initiated transitioning children to other potential sources of coverage. However, even with the continued uncertainty about future federal funding for CHIP, state officials remain hopeful that Congress will act soon to extend the program. States do not want to unnecessarily disrupt children’s coverage and are doing everything they can to protect their continuity of care.
While anxiety levels differ across states because they have different rules about noticing and are projected to exhaust funds at different times, over half of the states are likely to run out of federal funds within the second quarter of FY2018. Officials from several of these states have said they can hold off on making any changes until perhaps October, in the hopes that Congress is able to pass a 5-year funding extension that will offer them some predictability to continue to successfully operate their programs.
Cost Sharing Reduction Debate: Why This Matters and How States Are Preparing for an Uncertain Future
An update on CSRs – Aug. 18
Since publication of this blog, two major developments have occurred. The White House indicated that the Administration will make CSR payments for August. The Administration has not commented about future payments; the next is due Sept. 20. On Aug. 15, the Congressional Budget Office (CBO) released an analysis of possible impacts if CSR payments were terminated. Major findings include:
- A projected 20 percent gross premium increase in 2018 for silver-level plans; 25 percent increase by 2025 (based on March 2016 baseline). Premium increases would be used by insurers to make up for funding and instability caused by the loss of CSR payments.
- A $194 billion dollar increase in the federal deficit from 2017 to 2026. Increases could result from increases in premium tax credits provided to individuals because of the rise in premiums for silver-level plans, which are the benchmark plans by which tax credits are calculated. Increases would also be driven by a modest increase in insurance enrollment, which is expected because of the availability of higher net premiums available to some consumers.
- Issuer exits, then stabilization. Through 2019, insurers are expected to exit individual markets, leaving an estimated 5 percent of the population in regions with “bare” counties. In 2020, insurer participation is expected to increase as markets stabilize.
- Stable net premiums for marketplace consumers and some shifting of plan purchasing. Increased tax credits would mean that most individuals would pay premiums similar to or less than what would have been expected if CSRs had continued. CBO expects that those between 100 to 200 percent of the federal poverty level (FPL) would mostly continue to purchase plans at the silver-level, and those earning from 200 to 400 percent of FPL would switch to gold- or bronze-level plans. Of those in the 200 to 400 percent of FPL who switch plans, most are expected to purchase gold plans which, due to tax credit increases, would offer both higher actuarial values and lower premiums than silver plans.
The CBO score is based on many assumptions of projected market behavior and decisions that have significant weight on its findings.
First, CSR payments would remain funded through December 2017, meaning insurers would receive at least four more months of CSR funding before the program is eliminated.
Second, most states’ insurance commissioners would opt to have their insurers load the full cost of CSR payments onto silver-level plans offered through the health insurance marketplaces. As discussed in the blog, states are considering several contingencies in the case of CSR elimination, from fully loading the premiums onto marketplace silver-level plans to requesting that issuers split the load across all plans in the individual market.
Third, the CBO makes several assumptions about the projected behavior of employers and individuals, basing their estimates on a perceived increase in the value of on-marketplace coverage among both employers and individuals. The CBO assumes this will result in some employers dropping coverage, and in greater uptake of marketplace coverage among individuals.
Aug. 15
Today, the Affordable Care Act (ACA) includes several provisions designed to reduce the cost of insurance for consumers purchasing policies on individual markets. The Administration, Congress, states, insurers, and health policy stakeholders are currently debating the fate of these cost-sharing reduction (CSRs) programs and the result could significantly alter ACA markets in 2018. NASHP reviews what CSR payments are, the status of this critical debate, and how states are preparing for its possible impact.
Just what are cost-sharing reductions (CSRs)?
In addition to providing premium tax credits that make monthly premiums more affordable, the ACA includes CSR payments designed specifically to reduce out-of-pocket costs for lower income consumers. Individuals or families earning between 100 to 250 percent of the federal poverty level qualify for CSRs if they purchase a silver-level health plan through an ACA marketplace. The payments are delivered to insurers who, in turn, lower what consumers pay for copayments and deductibles. Every month, issuers receive CSR payments to cover these costs. Payments are calculated monthly based on consumer utilization of services. According to CMS, 7 million people have qualified for CSRs this year, and the expected payout to insurers — if these payments continue — is estimated at $7 billion in 2017, reaching $10 billion by 2018. The next payment to insurers is due Aug. 21.
What’s the debate?
In 2014, the House of Representatives sued the Obama Administration over CSR payments. They claimed the Administration violated the Constitution’s separation of powers mandate by authorizing payments to insurers though the language of the law, due to a purported drafting error, did not explicitly appropriate funding for CSRs. Congress argued that by directing funds to CSRs without Congressional appropriation, the Administration broke the law.
In September 2015, a judge ruled in favor of the House of Representatives. The Obama Administration appealed and the case moved to the D.C. Circuit Court, where it has received a series of extensions, during which the Administration continued to issue CSR payments. After the November 2016 election, the Trump Administration and the House continued to keep the case on hold. The most recent 90-day delay is due to expire Aug. 20, at which point the parties must decide if they wish to continue with the lawsuit or continue to extend the status quo. On Aug. 1, the U.S. Court of Appeals granted 17 states and the District of Columbia a motion to intervene in House v. Price, which would allow states to continue the case should the Trump Administration pull the Administration’s appeal. Meanwhile, the Trump Administration each month has debated whether to continue to issue payments for that month.
What does this mean for the insurance markets?
Elimination of CSR payments would have a significant impact on the stability of the individual market. If the Administration ends payments immediately, insurers will not receive the payments they were expecting to supplement the coverage they have already provided in 2017. Without an ability to adjust rates this year, insurers are expected to hike rates next year to account for the loss of CSR funding for the remaining months of 2017 and in 2018. An analysis of announced rate increases found that insurers are adding anywhere from 3 percent (Washington) to 23 percent (Idaho) extra to their premiums to compensate for a possible loss of future CSR funding.
Some insurers have announced their intent to exit the ACA marketplaces, citing uncertainty over CSR payments as one key consideration in determining their exit. It is predicted that others may follow suit if an official elimination of the payments is announced. In states where the Federally Facilitated Marketplace operates, insurers have the contractual right to end coverage midyear upon the loss of CSRs. To compound this instability, President Trump has indicated that the administration may choose to end payments if Congress fails to pass health reform legislation soon.
These changes would likely reverberate across the markets in important ways. Individuals who do not qualify for tax credits could bear the brunt of increases, potentially pricing out healthy individuals and, in turn, worsening risk pools. Increases in premiums for consumers who qualify for tax credits (individuals between 100 to 400 percent of the federal poverty level) would largely be offset by premium tax credits, which are calculated based on overall premium costs. Experts estimate that the increase in federal costs due to increased cost of APTC will outpace savings from ending CSR payments. The Kaiser Family Foundation and the Urban Institute predict that federal government spending could increase by $31 billion or $47 billion, respectively, if payments are eliminated.
What actions are states taking?
State regulators are leveraging flexibility and creativity as they work with insurers to navigate a challenging rate-filing environment. Colorado, New Hampshire, Oregon, and Kentucky as well as the Federally Facilitated Marketplace extended deadlines for their 2018 rate filings. As of Aug. 12, the federal deadline for final rate submissions has been pushed to Sept. 5, almost two months later than the 2016 deadline. In some states, including Utah and Pennsylvania, state departments of insurance have issued guidance instructing insurers to file two sets of proposed rates — one that assumes that CSR payments will continue, and another set that does not. California, Florida, Michigan, and Washington, have specified that insurers should file their second set of proposed rates so that calculations accounting for CSR changes are only applied to silver-level plans, rather than applying all plans. By loading all of the premium increases onto silver-level plans, which serve as the benchmark from which tax credits are calculated, bronze- and gold-level plans would presumably become more competitively priced. On the other hand, this may lead to pricing out consumers who do not qualify for the Advanced Premium Tax Credit (APTC), leading some states to ask insurers to spread the premium increase across all plan levels. States, including Maryland, have asked insurers to file rates that assume CSR payments will be maintained, with the caveat that they can refile if CSR payments end midyear. Premium rate requests are currently under review by state departments of insurance, with final decisions due for most states in September in order to be ready for Open Enrollment on Nov. 1. The longer these deadlines are delayed, the less time states will have to perform their typical pre-open enrollment activities.
What’s next?
Despite promises from Administration officials that an announcement about the future of CSR payments would be forthcoming, it remains unclear what that decision will be or when it will be announced. A possible solution to the CSR conundrum would be for Congress to appropriate funds. There are signals from Congress that such an approach could be in the works — two years of CSR funding was included in drafts of both the Senate and House ACA repeal bills, and the bipartisan House “Problem Solvers Caucus” included cost-sharing reduction payments at the top of their list of market stabilization strategies. Senate leaders on both sides of the aisle have stated that they want CSRs to continue to be funded. Meanwhile, U.S. Health and Human Services is taking steps to prepare for potential CSR changes, signaling it will issue changes through future rulemaking to account for any decisions around CSR. NASHP will continue to monitor the decisions of state insurance departments as they navigate the continued uncertainty.
Unpacking the State-Based Marketplaces
As policy makers debate the future of health care, the twelve state-based marketplaces (SBMs) and five state marketplaces using the federal platform (SBM-FPs) have proven themselves sustainable, solvent examples of how state flexibility can be leveraged to bridge public and private interests to improve lives and drive stable markets. As a result of these efforts, states operating SBMs and SBM-FPs have become leaders in promoting consumer choice, increasing enrollment, and making decisions for the health of their own markets.
Ensuring choice
As purchasers, many of the SBMs and SBM-FPs negotiate with issuers to ensure their marketplaces can offer products attractive to their target customers. Based on NASHP’s examination of initial filings, the majority of SBMs expect to retain stable issuer participation in their marketplaces in 2018. During this time, where federal policy uncertainty has raised questions over issuer participation, relationships between the SBMs and issuers has been especially pivotal to assure consumers will have access to a choice of products in the upcoming year. Together, issuers and SBMs are working to develop solutions and contingencies responsive to a potentially shifting environment.
Attracting and retaining consumers
SBMs and SBM-FPs are continually refining their marketplace strategies, developing new tools and methods to attract healthier, stable enrollees into their markets. During the 2016-2017 Open Enrollment Period, SBMs and SBM-FPs attracted 1,008,325 new consumers; about 71 percent of their total enrollees (2,457,567 individuals) were return customers (more details available on our chart). Research published by Covered California also found that SBMs, on average, boast a lower rate of attrition that the FFM, retaining 94 percent of total enrollment over OE3, compared to 85 percent (See Chart 1). Sustained retention is key to ensuring stability for issuers seeking consumers committed to a full year of coverage.
Maintaining a stable market
The efforts of SBMs, such as those described above, has encouraged the stabilization of insurance markets in recent years. Analysis of recent CMS data looking at the risk mix of enrolled populations indicates that SBMs and SBM-FPs attract a healthier risk mix into their marketplaces. Risk scores have continued to improve for the SBM and SBM-FP states since open enrollment; and in 2016, these states achieved a 7.7 percent lower risk score than states that use the FFM (See Chart 2). States’ success in maintaining market stability even in challenging times, reflects their “on the ground” knowledge of their customers, close working relationships with their insurance regulators and capacity to address changing policy and consumer needs.
SBM and SBM-FPs are full steam ahead on preparations to open enrollment on November 1, finalizing rate negotiations and operational changes to enable a successful opening. Throughout, NASHP will continue to monitor and report on their progress as the fifth open enrollment season approaches.
1 Chart 1: “New Federal Report Shows the Individual Markets Across the Nation Are Stable.” Covered California. July 6, 2017. Source
2 Available CMS data does not include Massachusetts, which operates its own risk adjustment program. Vermont is also not included from SBM calculations, due to the existence of a merged small group and individual insurance market in this state. Average risk score for Vermont’s merged market is reported as 1.55 in 2016.
State Levers to Advance Accountable Communities for Health
States are testing a myriad of models that strive to achieve the Triple Aim objectives of improved care, reduced health care costs, and better health. Though several statewide health care delivery and payment system reforms have been shown to help slow the growth of health care expenditures and improve methods for delivering health care, taken alone they are not enough to fully attain the Triple Aim goals. In an effort to improve the overall health of populations while further reducing healthcare costs, many state and federal health policymakers are partnering with communities to implement population health initiatives that engage new community partners to address the social factors influencing health such as housing, food, work, and community life. Among the models for implementing community-based interventions, Accountable Communities for Health (ACHs) are surfacing as a promising state strategy to integrate and align state health care delivery system transformation with community-based social services to create communities that promote health and well-being.
This brief and the accompanying state profiles identify state levers that advance ACHs by examining the ACH programs in California, Minnesota, Vermont, and Washington State. Specifically, this brief weighs the roles states and communities have played in establishing core ACH components including governance structures, geographic boundaries, financing mechanisms, priority conditions and target populations. It also considers state-level resources that can be leveraged to support and sustain ACH models going forward.
Full Brief
California State Profile
Minnesota State Profile
Vermont State Profile
Washington State Profile
State Strategies to Improve Health Through Housing Services
States are increasingly looking at housing as a component of health and well-being, particularly for individuals who are homeless or at risk of becoming homeless. Numerous studies show that housing supports for certain populations can improve health and reduce hospital expenditures and other costs for state and local governments. Some states are leveraging federal health care reform initiatives and Medicaid waivers to pay for housing services and supports; others are exploring private investment to support state efforts or examining successful local initiatives. In fact, the Centers for Medicare and Medicaid Services (CMS) Center for Medicaid and CHIP Services (CMCS) recently issued a bulletin describing state options for using Medicaid funding to support housing-related activities. Watch for additional NASHP projects on health and housing, as we bring our cross-agency Medicaid, public health, and behavioral health policy experience to bear on the pressing issues of health care and homelessness.
This chart contains state strategies to support health through housing services. The information is derived from state and federal documents, program descriptions, and other sources you will find linked in the text below. Special thanks to the Corporation for Supportive Housing, whose resources on Medicaid and housing have been invaluable.
Do you know of any state activities or emerging strategies that belong in this chart? Are you eager to update a fact we’ve included? Please send your suggestions, corrections or additions to aclary@oldsite.nashp.org. We rely on your contributions to keep our community’s real-time learning fresh and relevant. Thank you!
| Initiative Name | Funding Mechanism | What is Paid For | Target Population | Notes | Partners | Status | |
|---|---|---|---|---|---|---|---|
| California | California Bridge to Health Reform | 1115 waiver proposal | Rental subsidies, housing-based case management services, recuperative care. | Individuals who:
|
Concepts: “Health plans could use a portion of capitation payments to pay a case rate for housing-based case management services for eligible populations.”The Integrated Care Savings Pool [plans, counties, local donors contribute] would be used to fund rental subsidies, housing-based case management services, and recuperative care for eligible populations.”Alternatively, the State would allow health plans to fund housing costs as allowable costs for eligible populations.” | Regional partnerships of managed care organizations, city and county governments, hospitals, and housing and social service providers. | Proposal submitted March 2015; pending |
| California | ACA Section 2703 Health Homes | A care manager will facilitate referrals to supportive housing and social services. | High-cost, high-risk individuals with chronic conditions and/or serious and persistent mental illness. | Community-based care management entities (FQHCs, hospitals, clinics) and community support services. | Intends to submit 2703 SPA application in summer/fall 2015. | ||
| California | Los Angeles County Housing for Health | County funding–Housed within the LA County Department of Health Services (DHS) |
|
High utilizers of DHS services with complex medical and behavioral conditions. | Housing for Health is a county-run program that integrates health and behavioral health care with stable housing. | Case managers, health care providers, housing finance agencies, housing developers, philanthropic entities. | Active |
| District of Columbia | 1915 (c) waiver | One-time transitional services, including security deposits, furniture and linens, set-up fees or deposits for utilities. Lifetime max. of $5000 per individual. | Individuals with intellectual and developmental disabilities. | Providers of services including supportive employment, habilitative, and shared living services. | Active | ||
| District of Columbia | DC Permanent Supportive Housing Program | District Department of Mental Health funding | Permanent housing and supportive services | Homeless individuals and families who:
. |
Housed in Department of Human Services; Department of Mental Health uses its own funds to subsidize rent, and works with the DC housing authority to get rent subsidies. | District shelters or homeless service providers assess potential beneficiaries. | Active |
| Illinois | The Path to Transformation | 1115 waiver proposal | Performance incentive payments to MCOs could be reinvested into supportive housing capital, rental assistance, or services. | Individuals with serious mental illness and/or substance use disorders, including those who are homeless. | Illinois’s 1115 waiver would incentivize Medicaid health plans, Accountable Care Entities, and Care Coordination Entities who are at risk financially to invest in housing and housing supports for their patients by establishing an incentive-based bonus pool. | MCOs | Pending |
| Louisiana | 1915 (c) [and other 1915 waivers] Home and Community- Based Services waivers | Support for acquiring and securing housing, budgeting, establishing credit, and meeting tenancy obligations. Communicating with landlords about necessary accom- modations for disability. Also provides assistance when housing is jeopardized. | Individuals with a significant, long-term physical disability, and disabilities related to behavioral health and who meet low-income requirements. | Permanent supportive housing is part of the Community Choices 1915 (c) waiver. | Louisiana Housing Corporation | Active | |
| Massachusetts | Pay for Success | Social impact investment:
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Supportive housing | Chronically homeless individuals | The initiative aims to provide up to 500 units of housing over six years. | Corporation for Supportive Housing, Mass. Housing & Shelter Alliance, United Way | Launched in December 2014 |
| Minnesota | Hennepin Health (Hennepin County) | Medicaid ACOs | Housing and transportation assistance, work and financial support, care coordination. Housing navigation services to prioritized population. | Medicaid recipients who are enrolled in the Hennepin Health Managed Care Organization, including adults, families and children who are: homeless or unstably housed, identified as high risk for future costs, and whose health is directly impacted by their housing. | A 2014 Health Affairs article on Hennepin Health found that the program shifted care from hospitals to outpatient settings. | County Human Services and Public Health Departments; Metropolitan Health Plan, NorthPoint Health and Wellness Center; Hennepin County Human Services. | Active |
| New York | Health Home SPA | Comprehensive case management; health home networks partner with supportive housing providers. | Individuals with chronic conditions, including mental health or substance use disorders. | More information available here, here, and here. | Supportive housing providers, shelters, corrections systems. | Active | |
| New York | DSRIP/1115 waiver | Supportive housing services | Medical or behavioral health patients who are at risk during transitions into the community. | Select DSRIP projects address supportive housing. | Community housing providers home care service providers, others. | Active | |
| Oregon | 1115 waiver |
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Community organizations; state and county agencies. | Active | ||
| Oregon | Oregon Congregate Housing with Services (Pilot sites) | SIM | Social, support, and health services provided to individuals living in low-income housing or communities. | Low income single adults and people with disabilities in subsidized low-income housing or other low-income communities. | More information in the SIM grant narrative. | State agencies; housing, mental health, CCO constituent service organizations. | Active |
| Texas | DSRIP/1115 waiver | Varies by regional project:Supportive housing services; transitional housing services; patient navigators.
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Varies by regional project: Adults with SMI, HIV or TB; teens and young adults; chronically homeless individuals. | Other providers; community organizations. | Active | ||
| Texas | The Money Follows the Person (MFP) behavioral health pilot. | Money Follows the Person | A local relocation specialist works with the Texas Department of State Health Services to secure housing for individuals transitioning into the community. | Individuals transitioning from nursing facilities to the community. | See the June 2015 CMCS bulletin for more information on the Texas MFP program. | State and local housing agencies and organizations. | Active |
| Washington | Roads to Community Living | Money Follows the Person | Individualized housing-related services, including one-time-only moving expenditures. The program pays for services for one year after the person has moved into the community. | People with complex long-term care needs transitioning into the community from facilities | See the June 2015 CMCS bulletin for more information on Washington MFP program. | State and local housing agencies; human service agencies. | Active |
| Washington | Section 2703 Health Home SPA | Care coordination including referrals to housing resources. | Individuals with at least one chronic illness and at risk for another. | More information is available in the December 2014 interim report. | Community housing organizations; the state housing finance commission. | Active |
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Using CHIP and the ACA to Better Serve Children Now and in the Future
States have made great strides in providing children in families with low-to-moderate income appropriate and affordable health coverage over the past two decades through Medicaid and the Children’s Health Insurance Program (CHIP). The Affordable Care Act (ACA) created new coverage options for other populations, including parents who were previously uninsured. However, the ACA also includes provisions that support children’s coverage through exchanges and the Essential Health Benefit (EHB). Because federal funding for CHIP is not guaranteed beyond 2017, state officials are considering how to apply lessons learned from this critical program and use them to develop contingency plans to ensure strong children’s coverage into the future.
The National Academy for State Health Policy (NASHP), with support from the David and Lucile Packard Foundation, convened a stakeholder group of health policy experts that included national advocates and state officials representing Medicaid, CHIP and health insurance exchanges to explore the policy options states may have to maintain children’s coverage. This paper provides an overview of children’s current coverage options and summarizes the themes from the stakeholder group’s discussions that identified potential options for ensuring strong children’s coverage into the future.
Read the full brief.
View the brief graphs and appendix.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
