Health Coverage and Access – Page 48 – The National Academy for State Health Policy

Oral Health Precon Ebook

Final Oral Health Precon Ebook.compressed 11.7.16

Medicaid Incentives for Effective Contraceptive Use and Postpartum Care

October 5, 2016/in Policy Colorado, Oregon Blogs, Reports Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health /by NASHP Staff

Unplanned and complex births carry potentially avoidable health complications and costs to families and states. Broad healthcare payment and delivery reform is underway across the country to improve outcomes, enhance patient experience and reduce costs. Some states are capitalizing on these reforms to promote planned and healthy births by driving improvement in effective contraceptive use and postpartum follow up care. Their efforts create potential opportunities for cross-agency collaboration and integrate well with other initiatives, such as the Centers for Medicare and Medicaid Services’ Maternal and Infant Health Initiative and the Health Resources and Services Administration’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN).
Alabama, Colorado, Ohio and Oregon are among the states transforming the way they pay for and deliver healthcare across their Medicaid programs to increase accountability for quality and costs among providers and managed care entities. Key elements include performance measurement, reporting and performance based payment for a variety of services, such as family planning and postpartum care. Oregon has an incentive measure for effective contraceptive use, and Colorado and Ohio incentivize postpartum care visits. Alabama also plans to implement Medicaid delivery reform with incentives for postpartum visits.
Oregon has transformed its Medicaid delivery system by establishing a network of coordinated care organizations (CCOs) or community-based health entities responsible for providing integrated healthcare for Medicaid enrollees. The state has incentive measures for which CCOs can earn annual bonus payments. Last year, Oregon introduced an effective contraceptive use (ECU) incentive metric that tracks the percentage of women ages 18 to 50 who use a most or moderately effective contraceptive method.
Colorado has transitioned its Medicaid program into an Accountable Care Collaborative made up of regional care collaborative organizations (RCCOs) that coordinate care for members and contract with primary care medical providers. Medicaid withholds a small portion of the per member per month payment to providers and RCCOs that they can earn back by performing well on three incentive measures. In 2014, Colorado added its incentive measure for postpartum follow-up care use, which assesses the percentage of members who had outpatient postpartum visits following live births.
Ohio’s multi-payer payment and delivery system transformation includes episodes of care. The perinatal episode of care encompasses prenatal care, most delivery-related services and postpartum care. A principal accountable provider is responsible for the quality and cost of care delivered to the patient for the duration of the episode. Depending on average episode costs and performance on specific quality metrics, principal accountable providers may be eligible to receive an incentive payment or be subject to paying money back to the state. The goal is to encourage improvement by redistributing some cost savings back to the highest performers. One of the quality metrics that must be met for the perinatal episode is the percent of episodes with a follow-up visit within 60 days of birth.
Initiatives are still unfolding, with incentives for the perinatal episode of care in Ohio forthcoming, a second phase of Colorado’s initiative on the horizon, and plans in Alabama to establish regional care organizations in a Medicaid transformation model somewhat similar to Colorado that will include an incentive measure for prenatal and postpartum care. However, early results from Oregon and Colorado indicate improvement in support of planned births and healthy birth outcomes.
A new issue brief by the National Academy for State Health Policy (NASHP) in partnership with NICHQ explores experiences from Alabama, Colorado, Ohio and Oregon that demonstrate opportunities for cross-agency collaboration through payment and delivery reform to meet shared goals. States can consider aligning measures and incentives across Medicaid programs and Title V block grants, leveraging complementary data, and engaging state and local Title V or public health agency staff in Medicaid measure development and implementation to maximize resources and expertise.
For more information, download and read the new issue brief from NASHP/NICHQ: Opportunities for States to Improve Women’s Health and Birth Outcomes through Medicaid Incentives for Effective Contraceptive Use and Postpartum Care

NEXT STEPS FOR APCDs: US Department of Labor (DOL) Rulemaking

October 4, 2016/in Policy Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs /by NASHP Staff

Comments submitted to the DOL

The Gobeille v. Liberty Mutual Insurance Co. decision dealt a blow to state APCDs by denying state all payer claims databases (APCD) the ability to require data submission from self-funded group health plans. Nationally about 63 percent of all workers with employer-based health insurance are in self-funded plans and that number is growing. The loss of this large data set limits APCDs’ capacity to provide robust, all payer data on health care cost and quality. However, the Supreme Court’s decision, particularly Justice Breyer’s concurrence, suggested that the Department of Labor (DOL) may fix the loss of data to state APCDs by imposing a federal requirement that ERISA plans submit health care claims data.

On July 21 the DOL issued a Notice of Proposed Rulemaking requesting public comments on its proposed reporting requirements for group health plans, called Schedule J, and sought specific comments in light of the Gobeille decision. The deadline to submit comments has been extended to December, 2016.

NASHP convened a workgroup shortly after the Gobeille decision to examine strategies to secure self funded data while complying with the Court’s decision. In collaboration with the APCD Council and NAHDO, we have responded to DOL’s proposed rules.

These comments are the result of months of intensive efforts and review by all state APCDs to develop a proposal that will restore the data lost as a result of Gobeille within the legal framework of DOL’s current rulemaking.

In light of Gobeille, the DOL cannot simply grant states the ability to collect state-specific data. But the DOL does have broad responsibility for data collection from employee health plans. Our comments make the case that APCDs can assist the DOL meet its responsibility to oversee cost and quality in health plans and to provide a pathway, using Schedule J as a vehicle, to begin data collection as soon as the rule is finalized, not in 2019 when the rule proposes to operationalize Schedule J.

The NASHP workgroup created two subcommittees. One subcommittee, led by NASHP,worked to develop the legal foundation and proposal for DOL action pursuant to its rulemaking on Schedule J. That group identified the statutory provisions of ERISA and the Public Health Service Act that provide the DOL with the necessary authority to act and developed the policy argument describing how the DOL will benefit from working with state APCDs to collect and analyze health care claims data as well as the importance of supporting state APCDs’ work and access to data from self-funded plans.

But we recognized that, no matter how solid our proposal, the underlying concern of the Court about burden on reporting entities also had to be addressed head on. The second subcommittee, led by the APCD Council, worked to standardize reporting requirements . The Court found that reporting to multiple different states with different requirements posed a burden on reporting entities. The group addressed that burden by establishing a common data layout for all APCDs – a major accomplishment that will reduce that burden.

As a result of these efforts , NASHP, in collaboration with the APCD Council and NAHDO, submitted comments and a proposal that incorporate the following key elements:

Adoption of a standardized set of health care claims data, the Common Data Layout. The uniformity of the Common Data Layout is key to minimize burden to ERISA plans and adhere to ERISA’s goals of uniformity, consistent with Gobeille. Several months of intensive efforts were dedicated to the development of consensus among states, carriers, and data experts to adopt the Common Data Layout.
Any DOL requirement for plans to submit health care claims data must be tied to its proposed Schedule J. New substantive data reporting requirements from DOL must go through rulemaking procedures. Time is of the essence for State APCDs, so any proposal for collecting health care claims data must be integrated into this current rulemaking vehicle. Although Schedule J as proposed is inadequate to address the loss of data from state APCDs or DOL’s stated goals of improving transparency and oversight over group health plans, we propose a way for DOL to fill the gap to serve its own reporting needs and restore APCDs’ access to self-funded data.
We propose that DOL implement a pilot program to collect health care claims data in cooperation with State APCDs. The federal-state pilot approach is attractive because it allows DOL to leverage existing state APCD data collection and analytic capacity, reduces administrative burden and duplication, and leaves APCD investments intact. States would be granted authority to collect a uniform dataset from self-funded plans on a monthly or quarterly basis that would be aggregated into an annual report to the DOL to provide more robust data within Schedule J.

NASHP will continue its work with the APCD Council and NAHDO to monitor the rulemaking process and continue efforts to assure APCDs have the full capacity to collect all the critical data needed to address health care cost and quality.

Comments submitted to the DOL

Proposed HHS Notice of Benefit and Payment Parameters for 2018

October 3, 2016/in Policy Reports Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, State Insurance Marketplaces /by NASHP Writers

Earlier this month, the U.S. Department of Health and Human Services released its latest omnibus rule proposing a series of changes impacting insurance markets and the health insurance marketplaces. Our latest blog and accompanying memo break down a few key concerns for states as they finalize their comments due on October 6, 2016.
Memo: Proposed HHS Notice of Benefit and Payment Parameters for 2018
Blog post: Five Things to Watch from HHS’s Latest ACA Proposed Regulations

Potential Options and Policy Questions for Improving Exchange Coverage for Children

October 3, 2016/in Policy Blogs, Reports CHIP, CHIP, Chronic Disease Prevention and Management, Eligibility and Enrollment, EPSDT, Essential Health Benefits, Health Coverage and Access, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by Anita Cardwell

If federal funding is not extended for the Children’s Health Insurance Program (CHIP) beyond September 2017, some children may need to transition to exchange coverage. NASHP’s new brief examines potential options and policy questions for improving exchange coverage for children in terms of both affordability and pediatric benefit adequacy. NASHP convened a group of stakeholders including state officials, health policy researchers and advocates to explore ways to maintain affordable and comprehensive children’s coverage. The brief summarizes the key themes from the group’s discussion and builds upon the policy options identified in this previous NASHP brief. Attending #NASHPconf16? Be sure to check out our newly announced session on CHIP.

Read the full brief here.

Health Coverage Options for Pregnant Women

October 3, 2016/in Policy CHIP, CHIP, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Healthy Child Development, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, State Insurance Marketplaces /by Alexandra King

As a result of the Affordable Care Act (ACA) and the creation of health insurance exchanges, there are more coverage options for pregnant women in all states. In addition to insurance through exchanges, all states offer Medicaid coverage for pregnant women and a number of states also offer them coverage through their CHIP programs. Although there are coverage options for most pregnant women, these different coverage types do have different eligibility criteria, cost sharing and benefits.
NASHP has created a few resources to help explain the different eligibility criteria for multiple coverage options, including a chart that details income eligibility for each state’s Medicaid and CHIP programs from 2013 – 2015 and maps that highlight the income eligibility ranges. NASHP also created a couple of infographics (Julie, Samantha) that note enrollment steps for pregnant women with different income seeking coverage and raise policy implications for states.
View the chart
View the map
Path to Coverage for Pregnant Women: Julie
Path to Coverage for Pregnant Women: Samantha

Five Things to Watch from HHS’s Latest ACA Proposed Regulations

September 30, 2016/in Policy Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, State Insurance Marketplaces /by NASHP Writers

On September 6, 2016 U.S. Department of Health and Human Services released its latest proposed Notice of Benefit Payment Parameters; the annual omnibus rule to put into place regulatory changes impacting the health insurance marketplaces for the next plan year. Notably, the proposal was released several months earlier than usual this year, likely as a means to finalize changes and gather input prior to a transition of the new Administration.
The proposal includes many provisions that could significantly impact health insurance markets as well as the State-based Marketplaces (SBMs) and the Federally Facilitated Marketplace (FFM). Specifically, the Notice includes changes aimed at addressing affordability and market stability, as well as opportunities for greater state flexibility. Below we highlight five key concerns for states as they review the rule and formulate comments. Comments are due October 6, 2016.

The Notice is an open opportunity for states to share their ideas for what’s next for health reform and insurance markets. The notice includes many open-ended requests for more information and input on proposals that could significantly shape how the Affordable Care Act (ACA) operates in the years ahead. This includes open solicitations for input on specific policies such as special enrollment periods and spending on marketing and outreach, to a broad request for ideas of how HHS can facilitate issuer, provider, marketplace, or local innovation in ways that contribute to better health outcomes and lower costs. Combined with the recent Request for Information released by the Centers for Medicare and Medicaid Services in relation to the State Innovation Models Initiative, these mark important opportunities for states to share what lessons they have drawn from the ACA’s implementation to date, and how CMS can better support their goals for health reform moving forward.

The Notice attempts to resolve some current challenges impacting issuer stability and product availability. This comes mostly in the form of significant changes to the risk adjustment program (e.g., addition of new measurements to account for partial year enrollments, high-cost utilizers, and prescription drug spending) though other changes also merit notice such as:

new age rating bands for those under 21,
greater flexibility on events that would trigger an issuer “market withdrawal,”
adjustments to medical loss ratio and actuarial value calculations, and
clarification or revision of certain issuer responsibilities as conditions of marketplace participation (e.g., requirement that issuers offer one silver and one gold plan in each service area; requirement that plans remain available for the full duration of the coverage term.

Together, the changes attempt to address some recent issues that have led to premium spikes and issuer withdrawal from the marketplaces. Fresh from rate review, states have critical insight into how the proposals may ultimately impact their markets or how future regulations could further strengthen insurance markets.

The Notice heeds a demand for state flexibility and better alignment with state policies. Both states and the federal government have grown in their understanding of how marketplaces operate, and how functionally they work within the context of existing state and federal institutions and policies. Drawing upon these lessons, the notice offers several proposals that open opportunities for greater state flexibility. These include:

increased ability for states to propose alternative strategies for tax credit recalculation and data matching functions,
better alignment of state and federal definitions used for the purposes of risk adjustment; and
flexibility to enable marketplaces to function more efficiently within the capacity of existing systems (e.g., flexibility on provision of either paper-based or electronic notices, permanent extension of paper-based appeals process, increased ability to use enrollment data from certain government programs).

The Notice continues momentum toward fostering standard benefit models. To date, few states or issuers have adopted standard benefit designs, but states and the federal government alike have considered whether greater standardization could enable consumers to make easier comparisons between marketplace plans based on key factors like premiums and plan networks. While standard designs show some promise for driving efficiency through promulgation of value-based benefit offerings, issuers counter the designs have the potential to limit choice and constrain innovation of health plans. The proposals, including addition of a new high-deductible option, set new precedents for how benefit offerings may be shaped in the future and invite states to consider how the proposed designs may support or hinder the current offerings of insurance products

Proposed diminishment of SHOP functionality; establishment of a direct enrollment pathway could increase role of web-brokers and third-party administrators (TPAs). The Notice proposes two changes that could significantly enhance the ability of web-brokers or TPAs to assist in marketplace enrollment through both the FFM and Small Business Health Options Program (SHOP) marketplaces. The first establishes an “enhanced direct enrollment pathway,” which would simplify how consumers interface with web-brokers to complete enrollment. The second proposes elimination of certain SHOP functions, suggesting that TPAs or web-brokers may fill in for enrollment functions currently required of SHOP. The proposals most directly impact states operating in the FFM, but all states may wish to consider how federal and state regulations could be adjusted to account for the new potential role of web-brokers and TPAs, with attention to how these entities could support or supplement existing marketplace tools and the consumer protections that might be necessary to ensure fair and secure acquisition of affordable, quality coverage through these entities under the new structures.

NASHP continues its commitment to serve as a resource in monitoring and encouraging dialogue among states on these issues as states develop responses for the Oct 6 deadline. A more detailed analysis of the proposed regulations is available here.

Treatment for Children with Autism Spectrum Disorders and the EPSDT Benefit

September 19, 2016/in Policy Reports Behavioral/Mental Health and SUD, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Health System Costs, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by Barbara Wirth

State Medicaid agencies are working to provide comprehensive health care services for children with autism spectrum disorder (ASD), currently the fastest growing developmental disability in the United States for individuals under age 21. This brief highlights information from the 2014 CMS Informational Bulletin providing clarification on services to be provided to Medicaid-eligible children with ASD and, specifically, the expected adherence to the EPSDT benefit. Examples of strategies currently being used by multiple states to provide necessary treatment services are included.

Read the full brief here.

Intervention, Treatment, and Prevention Strategies to Address Opioid Use Disorders in Rural Areas

September 12, 2016/in Policy North Carolina Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Health Coverage and Access, Medicaid Managed Care, Physical and Behavioral Health Integration /by Chiara Corso and Charles Townley

A Primer on Opportunities for Medicaid-Safety Net Collaboration

The prevalence of substance abuse disorders in the United States has increased dramatically in the past 15 years with catastrophic consequences, especially in rural regions of the United States. Deaths and injuries from illegal opioid and heroin use are more prevalent in rural states, and death from opioid overdose is 45 percent higher in rural regions than urban areas.
Through a cooperative agreement with the Health Resources and Services Administration (HRSA), the National Academy for State Health Policy (NASHP) has developed this primer for Medicaid officials and healthcare providers working to reduce opioid addiction in their state’s rural areas. It details the role HRSA-supported safety net providers play in improving emergency medical intervention and treatment to Medicaid enrollees, many of whom live in rural regions, and low-income and vulnerable populations facing opioid use disorders.
Informed by interviews with key state Medicaid and health safety net leaders, this primer highlights strategies states are using to better deploy emergency intervention to reduce opioid overdose deaths, improve access to care, and provide better treatment services in rural areas. This report also describes sustainable financing structures to support these strategies and services.
Here are some of the successful initiatives highlighted in the report that are helping states reduce overdose deaths and improve access and quality of care for rural, low-income residents struggling with opioid addiction:

Authorizing first responders, pharmacists, and laypeople/bystanders to administer/distribute naloxone to reduce overdose mortality;
Reducing barriers to using medication-assisted treatment, such as methadone, naltrexone, and buprenorphine;
Enhancing state telehealth infrastructure to improve treatment expertise among providers in rural communities;
Implementing innovative insurance coverage strategies to expand substance use disorder treatment services, and;
Focusing enrollment efforts on rural populations at risk for opioid abuse to get them the treatment they need.

Ultimately, valuable lessons and effective strategies will continue to emerge from the nation’s opioid crisis and evolve over time. Through this process, states will play an important role in identifying and refining best practices for rural populations and developing strategies to address future challenges.
Read the primer.
View the infographic.

State Financing and Delivery Innovations to Address Disparities in Uncontrolled Childhood Asthma

September 9, 2016/in Policy Charts Behavioral/Mental Health and SUD, Care Coordination, CHIP, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Safety Net Providers and Rural Health /by Taylor Kniffin and Felicia Heider

The high prevalence of uncontrolled asthma among child populations served by Medicaid programs and the associated rising costs often are the impetus for states to improve the quality of care provided to children with asthma. New opportunities to comprehensively address asthma and its triggers are emerging through state and national health care delivery system and payment reform initiatives. NASHP identified state initiatives underway in Arkansas, Iowa, Michigan, North Carolina, Oregon, and Rhode Island that aim to address disparities and improve outcomes for children with uncontrolled asthma through innovative health care—particularly Medicaid—financing or delivery system strategies. The initiatives originate at either the state or community level and address the disease through a combination of clinic and community-based interventions, some of which focus on social determinants of health. The below table provides a cross-state analysis of the key strategies these six states are implementing to address childhood asthma and the accompanying case studies offer a more in-depth examination of each model. These resources are excerpts from a recent report released by MDRC in partnership with NASHP, “The Effectiveness of Interventions to Address Childhood Asthma,” which has more information on state and local efforts to improve asthma management among children in low-income families.

Comparison of Key State Asthma Program Features

		Arkansas Health Care Payment Initiative (episodes of care and PCMHs)	Iowa Health Homes Program	Michigan Asthma Network of West Michigan	North Carolina CCNC Asthma Disease Management Program	Oregon Healthy Homes	Rhode Island Home Asthma Response Program
Intervention Elements	Setting (Community or Clinic-based)	Clinic	Clinic	Both	Both	Community	Both
	Asthma action planning, education, care coordination	✓	✓	✓	✓	✓	✓
	Home visits			✓(up to 32)	✓	✓	✓ (3)
	Referrals	✓(e.g., smoking cessation)	✓ (e.g., smoking cessation)	✓(e.g., housing, transportation, counseling, prescriptions)	✓(e.g., child care, health consultants, transportation)	✓(e.g., food, housing, weatherization, legal, transportation, medical and mental health)	✓(e.g., WIC, adult education, weatherization, smoking cessation, mental health)
	Other services			Visits to school, child care, extended family		Supplies (e.g., vacuums, humidifiers, encasements, green cleaning kits)	Supplies (e.g., vacuums, filters, bed coverings, green cleaning kits)
Program Overview	Target population	Children and adults with qualifying events (episode of care); all Medicaid patients (PCMH)	Medicaid-eligible adults and children with 2 chronic conditions or 1 and at risk for second	Children and adults with moderate-severe uncontrolled asthma	Medicaid-eligible children and adults with asthma, prioritizing high-risk patients	Children <19 with asthma diagnosis, living in specific county, meeting Medicaid income requirements	Children ages 2-8 with recent ED visit or hospitalization residing in 3 specific cities
	Providers	Hospital physicians, PCP, or Pulmonologist	Designated practitioner, care coordinator, health coach and clinic support staff	Certified asthma educator (RN or respiratory therapist), licensed master social worker	Care manager (e.g., nurse, social worker, pharmacist), PCP	Nurse, CHW, environmental health and safety worker	Nurse educator, CHW
	Strategies to address disparities	Medicaid population focus; specific strategies vary	Medicaid population focus; specific strategies vary	Interpreters available; action plan in native language; target inner cities	Medicaid population focus; educational materials available in Spanish and English	Low-income population focus; bilingual staff, interpreters available; CHWs in disadvantaged areas	Diverse staff who receive cultural awareness training, offered in English and Spanish
Financing	Medicaid reimbursement	Retrospective episode-based payment	Tiered PMPM payment	Skilled nursing visits (4 Medicaid managed care plans)	PMPM payment	Targeted Case Management (specific counties)	N/A
	Medicaid reimbursement	PCMH PMPM payment	Tiered PMPM payment	Skilled nursing visits (4 Medicaid managed care plans)	PMPM payment	Targeted Case Management (specific counties)	N/A
	Other sources	Private insurer (separate episode of care initiative)	N/A	Local grants	Varies by Network	County funds; federal grants	Federal grants