Health Coverage and Access – Page 19 – The National Academy for State Health Policy

Meeting the Behavioral Health Needs of Diverse Populations

Ten States Selected to Attend Palliative Care Summit in Chicago

June 18, 2019/in Policy Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, Texas Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Long-Term Care, Medicaid Managed Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Writers

NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.

Changes to Poverty Measure Could Disqualify Thousands from State and Federal Programs

June 17, 2019/in Policy Blogs, Featured News Home CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Social Determinants of Health /by Anita Cardwell and Christina Cousart

The Office of Management and Budget (OMB) is seeking public comment on possible changes to how the federal poverty measure is annually adjusted for inflation. The changes would impact individuals’ eligibility for multiple programs because the US Department of Health and Human Services uses the poverty measure to establish poverty level guidelines. A wide range of government assistance programs would be affected, including:

Alternative methods proposed by OMB … could reduce the poverty line by up to 3.4 percent over the next 10 years.

Medicaid
Children’s Health Insurance Program (CHIP)
Advanced Premium Tax credits (APTCs) and cost-sharing reduction payments (CSRs) allotted through state health insurance marketplaces
Supplemental Nutrition Assistance Program (SNAP)
Women, Infants, and Children (WIC) program
Health Professions Student Loans
AIDS Drug Assistance Program
Community Health Center funding
Low Income Home Energy Assistance Program (LIHEAP)

Currently, the poverty measure is adjusted by a factor known as the Consumer Price Index for all Urban Consumers (CPI-U), which has been in place since the measure was implemented. While changes could affect long-standing eligibility for state and federal programs, OMB states that an alternative inflation index would more accurately measure inflation. Alternative methods proposed by OMB include use of the “chained” CPI or the Personal Consumption Expenditures Price Index (PCEPI) — these two measures grow more slowly than the CPI-U and could reduce the poverty line by up to 3.4 percent over the next 10 years.
Over time, a slower rate of inflation would significantly impact individuals’ eligibility for the programs listed above. At particular risk would be individuals whose income hovers at the margin of eligibility, who would lose eligibility if the calculation was modified. For example, estimates indicate that more than 500,000 would lose eligibility for Medicaid or CHIP, including 300,000 children. In addition, the millions of Americans who qualify for subsidies to purchase coverage through the insurance marketplaces would see a reduction in the amount of subsidies they receive that make coverage more affordable, or they could become ineligible for those subsidies altogether. Similar reductions in eligibility would occur across programs critical to social determinants of health, including food assistance programs (SNAP and WIC) and early education programs such as Head Start.
An increase in the number of low-income individuals who are no longer eligible for health and other social supports could have significant repercussions on states’ safety net programs. There will be a rise in the number of uninsured as individuals lose eligibility for, or are priced out of coverage. Some may use their limited income for necessities like food, child care, and utilities instead of health care. These changes could result in increased uncompensated care costs. Additionally, states’ health care system costs could increase if individuals without coverage delay seeking care and wait to seek treatment for conditions only when they become urgent — and more costly to treat.
Additionally, using the chained CPI may not fully account for the rising price of necessities that low-income households spend a larger percentage of their income to purchase, such as housing, which in recent years has increased faster than overall CPI. Many analysts, as well as the National Academy of Sciences, have noted that the current poverty measure already does not accurately capture important costs such as child care that strain many low-income families’ budgets.
Comments on the OMB proposal are due Friday, June 21, 2019 and can be submitted here. Following this comment period, it is unclear whether the administration will conduct a more formal rule-making process related to these potential changes, or simply seek to implement them through OMB guidance.

States Continue to Implement Surprise Medical Billing Protections

June 17, 2019/in Policy Colorado, Nevada, New Mexico, Texas Blogs, Charts Consumer Affordability, Health Coverage and Access, Health IT/Data, Health System Costs /by Christina Cousart

By Christina Cousart
Updated June 24, 2019
During the 2019 legislative session, states have continued to advance protections for consumers against surprise medical balance bills – charges for unexpected, out-of-network medical care. To date, four new states have enacted multi-pronged policies that prohibit balance bills, institute a process for providers and carriers to resolve billing disputes, and foster pricing transparency between providers, carriers, and consumers to avoid situations that lead to balance bills. Texas also approved legislation strengthening its existing consumer protections. Here are highlights of the new legislation.

	Colorado (HB 1174)	Nevada (AB 469)	New Mexico (SB 337)	Texas (SB 1264; HB 2041)[1]	Washington (HB 1065)
Balance billing protections
Holds consumers harmless	✓	✓	✓	✓*	✓
Prohibition in case of emergencies	✓	✓[2]	✓	✓[3]	✓
Prohibition in case of out-of-network (OON) services delivered at an in-network facility	✓[4]		✓[5]	✓[6]	✓
Applicable providers/ facilities	Person who is licensed or otherwise authorized in the state to furnish health care services including: ● Physicians ● Dentists ● Optometrists ● Anesthesiologists ● Hospitals ● X-ray ● LaboratoryExcludes ambulance providers, but charges the insurance commissioner with setting payment methods for ambulance services.	Physician or other health care practitioner who is licensed or otherwise authorized in this state to furnish any health care service; and institutions providing health care services including: ● Hospitals ● Surgical centers for ambulatory patients ● Skilled nursing facilities ● Residential facilities for groups ● LaboratoriesEmergency facilities include hospitals or independent centers for emergency medical care	Licensed health care professionals, hospitals, or other facilities licensed to furnish health care.Facilities include entities providing health care services including: ● Hospitals; ● Ambulatory surgical centers; ● Birth centers; ● Drug and alcohol treatment centers; ● Laboratory, diagnostic, and testing centers; ● Health provider’s offices or clinics ● Urgent care centers ● Freestanding emergency rooms ● Therapeutic health care settings	Individual licensed under the laws of this state to practice medicine or health care facilities.Facilities include: ● hospitals; ● Licensed ambulatory surgical centers ● Licensed chemical dependency treatment facility ● Renal dialysis facilities ● Birthing centers; ● Rural health clinics; ● Federally qualified health centers ● Freestanding imaging centers; ● Freestanding emergency medical care facilities*	Person licensed under state law to practice health or health-related services, or an employee or agent of such a person acting in the scope of their employment.Facilities include: ● Hospices ● Hospitals ● Rural health care facilities ● Psychiatric hospitals ● Nursing homes ● Community mental health center ● Kidney disease treatment centers ● Ambulatory diagnostic treatment or surgical facilities ● Drug and alcohol treatment facilities; ● Home health agencies.Carriers may not balance bill in the case of emergency services delivered by out-of-state providers.
Billing dispute and resolution procedures
Reimbursement standard	For emergency services the greater of: ● In non-Denver areas: o 105% of carrier’s median in-network rate for services provided at a similar facility in the same geographic area; or o Median in-network rate for the same service at a similar facility in the same geographic area based on all-payer claims database (APCD) data. ● In the Denver area: o Carrier’s median in-network rate for the same service in a similar facility in the same geographic area; o 250% Medicare rate for the same service in a similar facility in the same geographic area; or o Median in-network rate for the same service in a similar facility in the same geographic area based on APCD data. For OON services at an in-network facility, the greater of: ● 110% of carrier’s median in-network rate for the service in the same geographic area; or ● 60^th percentile of the in-network rate for the same service in the same geographic area based on APCD data.	For facilities: ● 108% of the previously contracted rate if the facility had been in-network within the last 12 months.● 115% of the previously contracted rate if the facility had been in-network within the last 12-24 months.● If no such contract existed, an amount the carrier determines to be fair and reasonable.For providers:If a provider had been in-network within the past 12 months: ● The previously contracted rate, if the provider terminated the contract before it was set to expire without cause; ● 108% of the previously contracted rate if the provider terminated the contract for cause; ● A fair and reasonable amount, determined by the carrier, if the carrier terminated the contract for cause; ● The previously contracted rate adjusted by the Consumer Price Index, Medical Care Component for the prior year, if neither party terminated the contract.If a provider had not been in-network in the preceding 12 months, carrier may remit whatever payment it determines.	A 60^thpercentile of the allowed commercial reimbursement rate for the service performed by a provider in a similar specialty in the same geographic area. Should not be less than 150% of 2017 Medicare rate. A stakeholder group will convene annually to review the reimbursement rate.	The usual and customary rate or an agreed-to rate, meaning the allowable amount as described by the applicable master benefit plan document or policy.*	Commercially reasonable amount based on similar services provided in a similar geographic area.
Process for arbitration	Baseball arbitration (arbiter will pick the final payment offer submitted by either the health plan or the provider/facility), if carrier and provider do not agree to initial payment. Arbiter will consider: ● Provider training, education experience, and specialization ● Previously contracted rate, if the provider had a contract with the carrier within a year of the dispute	Arbiter will either require the provider to accept the payment issued by the carrier as payment in full, or to demand that the carrier remit an additional amount requested by the provider.		Mediation may be requested through the Department of Insurance.[7] In the case of mediation of facilities, the mediator shall determine if the amount charged by provider is excessive, and if the amount paid by the insurer is unreasonably low or not the usual and customary rate. In the case of mediation for other providers, the mediator shall take into account whether there is gross disparity between the amount charged by the provider and how much the provider or similarly qualified providers receive for similar services. Other factors may include:* ● Patient characteristics and complexity of the services ● Provider training, education experience, and specialization ● 80th percentile of all billed charges for the service ● 50th percentile of rates for the service ● History of network contracts	Baseball arbitration (arbiter will pick the final payment offer submitted by either the health plan or the provider/facility), if carrier and provider do not agree to initial payment. Arbiter may consider: ● Evidence from the parties to assert the reasonableness of their offer ● Patient characteristics and complexity of the services ● Other relevant information include data from the state APCD
Data collection and reporting tools	State APCD		Benchmarking database maintained by a nonprofit organization specified by the insurance commissioner. Enables the commissioner to require carriers to report: ● The annual percentage of claims and expenditures paid to OON providers ● Changes to the percent of claims paid as emergency claims	The insurance commissioner is charged with selecting an organization to maintain a benchmarking database.	Requires state APCD to establish a dataset that provider, facilities, and carrier s may use to determine reasonable rates and to resolve payment disputes. Carriers shall provide information concerning the utilization of OON providers and cost savings yielded from the law as part of their annual rate filing.
Penalties
Provider must refund excess payments made by consumers	✓[8]		✓[9]		✓[10]
Penalty for violations	✓[11]		✓[12]	✓[13]*	✓[14]
Transparency standards
Must provide disclosure of potential repercussions of OON services	● Carriers ● Providers		● Providers[15]		● Carriers ● Providers
Requires cost estimates to consumers	✓[16]				✓[17]
Additional requirements:		On carriers: ● Must arrange for patient transfer within 24 hours of receiving notice that person is stable and can be transferred.On providers: ● Must send notice to carrier, no later than eight hours after person presents at an OON facility ● Must send notice to carrier that the beneficiary has stabilized and may be transferred to an in-network facility within 24 hours of stabilization	On carriers: ● Must make claims status information available to providers.On providers: ● Must post in a publicly accessible manner and online information about which carriers it contracts with. ● Must notify the carrier of a beneficiary’s admission within a reasonable period after stabilization. ● Any communication regarding bills, shall clearly state that the beneficiary is responsible only for in-network cost sharing amounts.	On carriers: ● Explanation of benefits must include information about balance billing protections; the total amount the provider may bill the enrollee under the enrollee’s health benefit plan; and an itemization of cost-sharing included in that total.* [18] On providers: ● Facilities must post notice that o it may charge a facility fee o it may charge rates comparable to a hospital emergency room o the facility or a physician at the facility may be OON and bill separately o Lists all the carriers it contracts with ● Facilities must provide patients with a disclosure that:* o Lists the facility fees that may result from the visit o Lists the carriers the facility is in-network with o Lists other cost information such as median facility fees and observation fees. ● Prohibits facilities from using logos or language to misrepresent that it might be in an insurers network.	On carriers: ● Must immediately arrange for an alternate plan of treatment if an agreement on post-stabilization services cannot be reached with the emergency provider. ● Must update provider directory within 30 days after the addition or termination of a provider.On providers: ● The provider must contact the carrier within 30 minutes of stabilization before rendering further services. ● Must post online information about which carriers it contracts with. ● Must provide carriers with updated lists of non-employed providers working at the facility

*Indicates changes made by the new Texas law.
[1] Texas’ 2019 law amends and enhances already existing protections in the state. Changes made by the new law are noted by asterisk.
[2] Does not apply when: 1) Services are received at a critical access hospital; 2) A person is covered by insurance sold outside of the state; 3) Services provided more than 24 hours after notification has been provided and a person has been stabilized.
[3] In the case of a beneficiary who cannot reasonably access a preferred provider, the protections extend to 1) medical screening and examinations require to determine if a medical emergency exists; 2) necessary emergency services to treat and stabilize; 3) services originating in an emergency facility following stabilization; and 4) supplies related to the services rendered by that facility.
[4] Does not apply if the consumer affirmatively consented to receive OON services.
[5] Only applies when; 1) A participating provider is unavailable; 2) Medically necessary care is unavailable in the beneficiary’s network (determined by the provider in conjunction with the health plan); or 3) the patient did not consent to receive services from the OON provider.
[6] Does not apply in the case of a beneficiary that elects, in writing and in advance, to receive services from the out-of-network provider, or in the case that the provider does provide the enrollee with a written disclosure that they are out-of-network and provides an estimate of the projected amount the enrollee will be responsible for. Explicitly includes protections for OON services delivered by diagnostic imaging or labs.
[7] Prior law allowed mediation requests only in the case of claims over $500 and that were for either emergency services, or services rendered by a provider or supplier at an in-network facility.
[8] Refund must be issued within 60 days, or interest will accrue.
[9] Refund must be issued within 45 days, or interest will accrue.
[10] Refund must be issued within 30 days, or interest will accrue.
[11] Punished by a fine of not more than one thousand dollars, or by imprisonment in the county jail for not more than one year, or both.
[12] Insurance superintendent may impose a fine on any provider that offers an unlawful rebate or inducement to entice a person to seek OON services
[13] The Attorney General may bring civil action against entities that exhibit a pattern of repeatedly violating billing protections. Authorizes applicable agencies to take action against providers or facilities who violate billing protections. The Secretary of State may suspend or revoke a license, or bring civil action against entities who violate the disclosure requirements outlined under Texas law. The Department of Health may impose penalties up to $1,000 for certain violations.
[14] Authorizes the Department of Health or an appropriate authority to levy fines against providers or facilities who violate these policies. Commissioner may levy a fine against carriers who violate these policies. Repeated violation may constitute unprofessional conduct and risk licensure of a provider or facility.
[15] If an OON provider has advanced notice that the beneficiary is OON, they must notice the beneficiary of their OON status and recommend the beneficiary contact their carrier to discuss options.
[16] A provider must issue a cost estimate within three days if requested by a patient.
[17] Carrier must provide an estimate of out-of-pocket costs for OON services upon request.
[18] Applicable to Health Maintenance Organizations.

Eliminating Hepatitis C: New State Payment Models for Treatment and Emerging Evidence

June 3, 2019/in Policy Louisiana, Washington Blogs Administrative Actions, Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Value-Based Purchasing /by Maureen Hensley-Quinn

With hepatitis C infections on the rise and curative, but expensive, prescription drugs now available, state leaders across the country are compelled to address this public health crisis, and Louisiana and Washington are developing innovative drug-purchasing strategies within their efforts. At the same time, the Patient-Centered Outcomes Research Institute (PCORI) is investing in patient-focused studies into hepatitis C treatment to help fill gaps in our knowledge with a patient focus to help guide future state efforts to combating this deadly liver disease.

During this National Academy for State Health Policy (NASHP) webinar, officials from Louisiana and Washington share their approaches to using negotiated fixed price payments to ensure unlimited access to hepatitis C drugs for individuals with public health coverage.

Since 2010, the number of new infections has tripled, which experts attribute to the opioid crisis and an increase of people who inject drugs. A growing number of states are committing to eliminating hepatitis C as the World Health Organization, the US Centers for Disease Control and Prevention, and others are advocating. Such a commitment is possible due to drugs introduced in 2011 that can achieve cure rates above 95 percent when the 12-week treatment regimen is followed. However, the costs of these drugs in the United States remains high even though prices have dropped since their introduction. Although prescription drugs are just one component of states’ comprehensive public health hepatitis C elimination campaigns, the high cost of these drugs is the one of the biggest challenges facing states as they address this growing public health crisis.
Although their payment strategies are slightly different, Louisiana and Washington are exploring agreements with drug manufacturers to pay a flat fee over a contracted time period to gain unlimited access to hepatitis C drugs, rather than pay on a per unit basis, which is how most drugs are purchased. In Louisiana, corrections system populations and individuals enrolled in Medicaid and will have access to the drugs. In Washington , incarcerated individuals, Medicaid enrollees, public and school employees, individuals covered by workers compensation, and those in state hospitals will have access to the drugs as needed.
During this National Academy for State Health Policy (NASHP) webinar, officials from Louisiana and Washington share their approaches to using negotiated fixed price payments to ensure unlimited access to hepatitis C drugs for individuals with public health coverage.
As states forge ahead to design and implement strategies to eliminate hepatitis C and find ways to ensure access to treatment while working to contain costs, PCORI research is seeking to learn more about:

Effective screening to identify more cases;
What harm results, compared to no treatment;
Direct comparison of treatments in the real world; and
Effectiveness of care delivery models.

As results from these ongoing patient-centered research studies become available, they will help inform evolving state efforts to address the hepatitis C crisis. The introduction of the effective drug treatment has changed states’ public health approaches and incentivized Louisiana and Washington’s innovative purchasing strategies.
According to an overview of PCORI’s hepatitis C research highlighted during the webinar, researchers are hoping to learn how to most effectively engage people living with hepatitis C who use injection drugs to provide treatment that works. Patient-centered research is also seeking to learn more about the prevalence of re-infection. The evidence from these studies will help with clinical interventions, but could also be taken into consideration as states design, implement, and review their public health campaigns and treatment payment strategies.
Emerging issues, such as public health crises, require immediate attention and innovative cost-effective solutions from state officials. States’ call to action to address the rise in hepatitis C infections is an example of how they must react quickly using the information, appropriate lessons learned, and resources they have to address current crises. State officials are designing their drug contracts and plans to be as flexible as possible so they are able to adjust their approaches as new information becomes available, such as new PCOR evidence. As Louisiana and Washington learn from their prescription payment model and evidence becomes available from PCORI about treatment outcomes and approaches, state efforts will continue to evolve.

States Lead on Surprise Medical Billing Protections, Congress Poised to Follow

June 3, 2019/in Policy Charts Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs /by Christina Cousart

State Surprise Medical Billing Laws Can Inform the Congressional Debate

May 28, 2019/in Policy Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs /by Christina Cousart, Trish Riley and Maureen Hensley-Quinn

As Congress and the Trump Administration propose strategies to address surprise balance billing – charges for unexpected, out-of-network medical care – states have significant experience in implementing surprise billing laws that can inform the discussion. Importantly, state authority cannot protect individuals covered by self-insured plans, which are pre-empted by Employee Retirement Income Security Act (ERISA,) from state oversight. To extend protections to consumers covered by these plans federal action is needed either through mandated protections or a change in law to enable states’ laws to apply toward ERISA plans.
States’ approaches to addressing surprise balance bills vary in how they:

Define what services are covered by these protections;
Address how reimbursement for services should be resolved; and
Define provider and insurer transparency requirements.

Through National Academy for State Health Policy’s (NASHP) work with states, it has identified the following themes and lessons from state laws and experiences that could help inform future federal action on surprise balance bills.

Broadly define services covered by the law.

Balance billing protections are strongest when they extend to both all emergency circumstances and situations where the consumer does not have control over the out-of-network (OON) services provided. Such situations can occur without consent of the patient when an in-network physician is unavailable, because of an unforeseen medical situation, and/or because of a direct referral to an OON provider or facility rendered by an in-network provider. Surprise balance billing laws that include provisions to extend protections broadly across multiple provider and facility types, including specialists, labs, imaging centers, and air and land ambulance transport, offer the strongest consumer protections.

Consider multiple factors when determining the law’s dispute resolution process.

Essentially, state laws take two approaches to resolve billing disputes for surprise balance bills – setting a specific reimbursement rate for such bills and/or defining an arbitration process through which providers and insurers can resolve payment disputes. Because many state balance billing laws are nascent — and have been implemented during a time of considerable policy change affecting health care markets — there is a lack of evidence identifying the ultimate effects, either positive or negative, of either approach on state health insurance markets, including their impact on premium costs and provider network composition. Both approaches have challenges. Setting reimbursement rates for balance bills can be challenging given the multiple stakeholders involved and there is time and expense to consider in establishing fair mediation or arbitration systems. Whatever strategy Congress adopts, states’ experiences suggests the following factors for consideration:

Remove consumers from billing disputes. To maximize consumer protection from surprise balance bills, the process for resolving reimbursements should be kept between the insurer, the provider, and any agency appointed to aid in resolution. To encourage this, additional requirements may be put in place to foster direct communication between providers and insurers, such as a requirement that insurers alert providers about what, if any, ability they will have to balance bill for services rendered to the insurer’s beneficiary. (For example, multiple states require insurers to include this information in their Explanation of Benefits sent to providers.)
Use of data sources that leverage claims data. By using this data, such as that collected by all-payer claims databases (APCDs), reference price amounts for negotiations for medical bills will be based on actual paid amounts, rather than billed amounts. The latter may lead to inflated rates and higher health care spending. However, not all states have APCDs. Including funding to support state APCD programs could be an impetus to improve access to needed claims data in every state. To assure the most robust data collection, however, requires Congressional action to amend ERISA or provide other means for states to mandate the collection of claims data from self-funded plans. The Supreme Court’s ruling in Gobeille v. Liberty Mutual currently prohibits such requirements. While states do encourage voluntary reporting with some success, a mandate would assure more consistency in reporting. One of the issues identified in the Gobeille decision was the burden on self-funded plans created by different reporting requirements in different states. Including reference to the common data layout developed by states would resolve that reporting burden question.
Inadvertent effects on provider networks and contracts. The ultimate reimbursement rates paid to resolve surprise balance bills should provide sufficient compensation to providers, without incentivizing providers to stay OON. For example, a benchmark that provides payments set too high may incent providers to remain OON. However, payments set too low may impose negative impacts on providers already operating on the margins. To protect against the latter, reimbursement calculations may consider a variety of factors, including average payment amounts for similar services, geographic cost variation, provider experience, or other factors unique to the situation of the service performed.
Set a fixed amount for consumer cost sharing. This added protection will guard consumers from potentially exorbitant out-of-pocket costs in the case that final reimbursement rate decisions on a balance bill result in large out-of-pocket cost-sharing for services from deductibles, coinsurance, etc.

Include prohibitions on billing practice and hold harmless protections.

The most protective strategy would be an explicit prohibition on the part of providers or insurers from balance billing patients. While this should absolve consumers from the surprise billing burden, the law should also be clear in holding consumers harmless in situations where a balance bill is being negotiated between insurers and providers. This may take the form of specifying what form of contact, if any, insurers and providers may take with consumers regarding billing disputes and prohibiting certain actions, like credit reporting, against consumers.

Encourage enforcement through federal penalties.

Because of their limited jurisdiction over providers and certain health plans, enforcing surprise billing protections has been a challenge for some states. A successful federal law would include an enforcement mechanism that would support additional compliance with surprise balance billing laws.

Include deference to existing state laws.

States, including those with robust balance billing protections, have taken very different approaches to crafting their laws. This wide variation reflects states’ diligent and deliberate work to find solutions to surprise balance billing that work best for their markets.
States’ experiences can inform Congressional proposals and deliberations to address balance billing – from requiring transparency about networks and service costs to establishing the processes to determine the reimbursement rate for an OON provider. States have acted to protect consumers, experimenting with a variety of strategies to protect consumers from unexpected financial exposure. Federal action can extend the reach of those protections to include consumers covered by self-funded, employer-based insurance, but it should consider how any new federal law will impact state progress in this important arena of consumer protection.

A New State Tool to Manage Drug Costs: Experts Share Insights into Outcome-Based Contracts for Medicaid Pharmacy Claims

May 27, 2019/in Policy Colorado, Michigan, Oklahoma Blogs Administrative Actions, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Quality and Measurement, Value-Based Purchasing /by Jennifer Reck

Colorado and Michigan have joined Oklahoma to become the nation’s pioneering states with approved State Plan Amendments (SPAs) that enable Medicaid alternative payment models (APMs) for prescription drugs in the form of outcome-based contracts with pharmaceutical manufacturers.
In early May, state experts from Oklahoma, Colorado, and Michigan shared their experiences implementing their APMs during a NASHP webinar. A recording of the webinar is available here.

Experts from Oklahoma, Colorado, and Michigan shared their experiences implementing their outcome-based Medicaid alternative payment models during a recent NASHP webinar. Listen to the webinar here.

The SPAs enable states to negotiate contracts based on agreed-upon outcome measures tailored for specific drugs. Outcomes measures vary but may include measures such as patient adherence or reduced hospitalizations. If the drug’s performance fails to meet agreed-upon outcomes and triggers the need for additional manufacturer payments to the state, those payments are made in the form of supplemental rebates. The contract template was developed with the support of the State Medicaid Alternative Reimbursement and Purchasing Test for High-cost Drugs (SMART-D).
Though these outcomes-based APMs are valuable tools for states to manage escalating drug costs, APMs are best understood as “one more tool in our toolbox,” which are most effective when used in tandem with other strategies rather than in isolation, explained Cathy Traugott, pharmacy office director of the Colorado Department of Health Care Policy and Financing. Though these APMs may help states manage payment for high-cost drugs, the high-list prices themselves remain a problem that states are also attempting to address head on. During this year’s state legislative session alone, 47 states have filed 254 drug-cost-related bills (as of May 22, 2019).
Executing and implementing outcome-based contracting can be a time-consuming endeavor for states because of the necessity for state officials to engage with multiple manufacturers in exploratory discussions to identify drug candidates, followed by the data analysis necessary to design, and then track the outcome-based measures.
Oklahoma, whose work NASHP supported through a subgrant from the Laura and John Arnold Foundation, found that the process took longer than anticipated. Terry Cothran, director of the University of Oklahoma’s College of Pharmacy, advised states that pursue outcomes-based contracting to consider dedicating a project coordinator to execute the work most effectively.
To date, these contracts are with state Medicaid agencies only, and have not included inter-agency efforts. Rita Subhedar, state assistant administrator for Michigan’s Department of Health and Human Services, stressed the importance of broad engagement within a Medicaid department to effectively implement these APMs, including pharmacy, medical, and behavioral health staff. A separate, subscription-based payment approach, known as the “Netflix” model, utilizes a cross-agency approach engaging both Medicaid and a state corrections department. This approach was explored in another NASHP webinar, How States Pay for Hep C Drugs Using a “Netflix-style” Subscription Model.
The first results from outcome-based contracting will come from Oklahoma, whose first, one-year contract is scheduled to end July 2019, with three other contracts concluding soon after. Colorado and Michigan have not yet executed contracts.

Leveraging CHIP to Improve Children’s Health: An Overview of State Health Services Initiatives

May 20, 2019/in Policy Charts, Maps CHIP, CHIP, Chronic Disease Prevention and Management, Eligibility and Enrollment, Health Coverage and Access, Healthy Child Development, Maternal, Child, and Adolescent Health, Population Health /by Anita Cardwell

“So You Want to Build a State-based Marketplace? Here’s How!” — Advice from Marketplace Leaders

May 20, 2019/in Policy Blogs Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by Christina Cousart

Where States Stand on Exchanges

States that control their own insurance marketplaces – called state-based marketplaces (SBMs) – are leaders in providing affordability and choice, outperforming the federal marketplace on notable markers including higher enrollment, lower premium rate hikes, more participating issuers, and successfully attracting a young consumer base. These accomplishments are especially notable given recent federal policy actions that have unsettled insurance markets and a national rise in uninsured rates.
The success of SBMs results from years of hard work spent cultivating their markets while building operational and technical systems tailored to serve their states’ consumers. Thanks to the work of these SBMs and the evolution of new technology, it is now easier (and cheaper) for states currently using the federal platform to switch and adopt the SBM model.

What’s so different about SBMs?
Ten states and Washington, DC (representing nearly 25 percent of the US population) operate SBMs, meaning the state has taken full authority to build and maintain its health insurance marketplace.
SBMs consistently outperform states that use the federal marketplace in areas of enrollment, affordability, and increased plan offerings and competition.
Their flexible structure allows SBMs to focus marketing and outreach efforts to state-specific needs and promote policies that generate more health coverage choices at lower costs.
Click here for more information about SBMs.

As new states express interest in the SBM model, they can learn much from the leaders who have pioneered implementation of this model.
Earlier this month, the National Academy for State Health Policy (NASHP) hosted a webinar with SBM leaders from Idaho, Nevada, Massachusetts, and Washington, DC to showcase some of their lessons. Highlights are featured below, and a recording and slides from the webinar are available here.

Focus on the Basics (and Avoid Scope Creep)

SBMs provide more than “shop-and-compare” websites for consumers shopping for health insurance — SBMs are dynamic business enterprises. While their main objective is to make sure that individuals have “easy access to health coverage,” SBMs must also:

Perform a series of complicated eligibility and enrollment functions easily;
Work with the systems of partner organizations, including carriers, Medicaid, and outreach partners; and
Be financially sustainable.

Rather than get carried away by bells, whistles, and complex policy aspirations, SBM leaders advise that future SBMs must first focus on building a functional, sustainable system. Once a working SBM is established with a long-term financing strategy, it can always grow and evolve to perform new functions.

Prioritize the Consumer Experience

Much of an SBM’s success depends on its ability to attract and retain consumers. Over the years, SBMs have worked diligently to improve the experience of its consumers. As Massachusetts Health Connector Chief of Policy and Strategy Audrey Gasteier explained, “Marketplaces require a lot of activity on the part of a consumer,” and it is important that consumers feel empowered. Outreach is a major component of this work — from providing educational materials to in-person assistance provided by brokers, Navigators, and certified application counselors. Earned press coverage and social media are also effective tools for SBMs to quickly spread the word about their products and policy changes at low cost. Speakers also noted the importance of call centers and recommended that states equip their centers with self-service capabilities so that consumers can easily resolve common issues over the phone.

While “out-of-the box” technology and adaptable systems make it easier than ever to for a state to build a marketplace, directors cautioned states not to be too aggressive in their planning and timetables. As with any large-scale project, states should anticipate delays and challenges.

Set Clear Expectations and Timelines

Heather Korbulic, executive director of Nevada’s SBM, presented an 18-month timeline for implementation of an SBM — from passage of enabling legislation to the marketplace’s first open enrollment period. While “out-of-the box” technology and adaptable systems make it easier than ever to for a state to build an SBM leaders cautioned states not to be too aggressive in their planning and timetables. As with any large-scale project, states should anticipate delays and challenges. For example, from the start states need to work closely with federal officials from the Center Consumer Information and Insurance Oversight (CCIIO) to establish their marketplace “blueprint.” While CCIIO experts serve as an important resource for states — providing years of technical and policy expertise to help guide states — implementation of an SBM requires strict federal oversight and approvals that may cause delays that are outside of the control of a state.
Throughout the SBM implementation process, leaders emphasized the importance of maintaining transparency so that stakeholders are not deterred by unexpected delays or issues. By keeping stakeholders informed of progress and expectations, an SBM will cultivate trust and maintain relationships critical to the marketplace’s long-term success.

Relationships Are the Foundation of an SBM

Any marketplace cannot function without engagement across a mix of stakeholders, which include:

State policymakers who will establish the marketplace;
Federal officials who will oversee and approve its implementation;
Insurance carriers who will sell products through the marketplace; and
Consumers whom the marketplace will serve.

Stakeholders will have different — and sometimes conflicting — interests and it is the job of the marketplace to balance those interests in pursuit of mutual goals. Leaders underscored the importance of insurer engagement, recognizing the central role of health plans in the success of the marketplace. Establishment of an SBM will require insurers in the state to establish new business practices. A state should not underestimate the uniqueness of how each carrier operates and the time it may take for each to adapt to the new SBM system.

Establish Clear Leadership that Can Take Quick Action

A state has the flexibility to choose how to establish its SBM — either as a state agency, a non-profit, or a quasi-public-private entity. Because an SBM must be responsive to changing consumer and insurer markets and be able to readily contract with vendors to develop needed services, it is best that an SBM assume a governance structure that can enable it to act quickly. Moreover, leaders directors noted the importance of leadership to any marketplace. While operation of an SBM takes a team, it is important to have one person who is clearly designated to establish priorities, take accountability, and make decisions to get the SBM “across the finish line.”

SBMs Serve as a “Hub” for Health Reform across State Agencies.

Regardless of the specific model chosen, SBMs must be able to work across existing state agencies including Medicaid, insurance departments, and other health policy agencies. SBMs are uniquely positioned to serve consumers who range from those on the cusp of Medicaid eligibility to those accustomed to various types of commercial market coverage. To ensure smooth processes for consumers, SBMs must be able to navigate between agencies to ensure that its policies and operations are consistent with what is being promulgated by its sister agencies.
For instance, SBMs are required to generate many different types of notices to consumers, such as information related to a consumer’s eligibility for coverage programs. SBMs coordinate closely with their Medicaid agencies on the language and process for sending these notices to help reduce confusion for consumers who might otherwise receive duplicative or misaligned information from both agencies. Additionally, because SBMs serve consumers who are eligible for federal tax credits, they serve an important role in informing state and federal policymakers about how policy changes may directly impact their consumers. To serve this role, it is important that SBMs have sufficient analytic capacity to process data on their consumers and advise on the implications of changing federal and state policies.

Let SBMs Adapt Over Time

Insurance markets and marketplace consumers are not static, and SBMs must be able to adjust to changing needs and consumers. They must constantly work to engage new consumers who may be coming in and out of other coverage programs (e.g., leaving parental coverage, employer-sponsored insurance, or Medicaid), while also adapting to evolving expectations as consumers interact more and more with e-commerce and advanced technology. Through consumer surveys and testing, SBMs are constantly learning and adapting their services. One benefit of their flexible structure is that SBMs are also becoming more sophisticated and efficient in navigating this process. Some have even been able to cut operational expenses and lower the assessments they charge to carriers who sell on their exchanges, which, in turn, results in lower consumer premiums. For example, Mila Kofman, executive director of DC Health Link, estimates her SBM was able to save approximately $2 million annually by moving its data servers to a cloud-based system in 2016.
Most notably, leaders point out that each SBM has taken a unique approach in how it has operationalized its marketplace. In the process, each has learned lessons from their SBM peers — from simply sharing effective marketing strategies to full partnerships, like Massachusetts’ adoption of Washington, DC’s technology for its small business marketplace. In this spirit, speakers advised states to learn from their peers as they work through their own challenges on the road to implementing SBMs.
NASHP and the SBMs are ready and eager to help support states as they contemplate establishing their own SBMs. For additional resources about SBM models and implementation, explore NASHP’s State Exchange Resource Hub.