Tag: Medicaid

CMS Issues Final Marketplace Stabilization Rule

Last week, The Centers for Medicare and Medicaid Services issued the final Marketplace Stabilization rule to “help lower premiums and stabilize individual and small group markets and increase choices for Americans.” While the rule is designed to help lower premiums and increase the choices consumers will have, some of the policy changes in the rule may potentially impact consumers in a negative way. Below are the key components of the final rule:

2018 Open Enrollment Period: The final rule shortens the annual open enrollment period to November 1, 2017, until December 15, 2017. This is half the duration of open enrollment periods in the past. This shortened window to enroll will result in many consumers potentially missing the opportunity to enroll in coverage and will overwhelm the already limited capacity of organizations providing in-person enrollment assistance. During the 2016 Open Enrollment period for the New York State of Health Marketplace (November 1, 2015 – January 31, 2016), about 74% of consumers enrolled or renewed their coverage with the help of an assistor. Consumers that do not enroll during the open enrollment period will only be able to enroll if they are eligible for a Special Enrollment Period (those eligible for Medicaid, Child Health Plus or the Essential Plan can enroll at any time during the year.)

Special Enrollment Period: Individuals applying outside of open enrollment will be required to provide proof of eligibility for a special enrollment period by submitting supporting documents. This rule aims to reduce fraud and abuse by ensuring that only those who are eligible are able to enroll. Consumers are not currently required to submit proof and this additional documentation burden could result in consumers experiencing delays in their coverage.

Continuous Coverage: The final rule allows insurers to require individuals to pay back past due premiums before enrolling in a plan with the same insurer the following year. Consumers who fell behind in premium payments will have to pay the balance due or they will not be able to enroll in the same coverage, forcing consumers to choose between overcoming a financial burden or being locked out of coverage for the entire year.

Ensuring Additional Choices for Consumers: the final rule allows insurers additional flexibility with the actuarial value of plans so they can offer more plan choices with lower premium options. While at first glance it does seem beneficial to offer greater consumer choice, actuarial value flexibility will allow insurers to offer cheaper plans by removing benefits or increasing out of pocket costs. Consumers may not realize what benefits are not being offered with their plan or what out-of-pocket costs they will be responsible for.

While overall these policy changes may be aimed at increasing choices and lowering costs, a robust education and outreach component should also be included to ensure that consumers understand how these changes may impact their coverage.

State-run marketplaces, like the New York State of Health, do often have more flexibility in establishing some of these policies so it is not entirely clear at this time how this final rule will impact consumers currently enrolled or enrolling in coverage through the New York State of Health Marketplace. HWCLI will continue to follow these changes and provide further updates when additional information is provided by the state.

Census Data Shows Drop in Uninsured

According to a new federal survey released this week by the U.S. Census Bureau, number of uninsured Americans declined from 13.3 percent of the population in 2013 to 9.1 percent in 2015. Uninsured rates declined across all age groups with adults ages 19-25 experiencing the biggest one-year drop. The uninsured rate among adults ages 19-25 dropped by 2.6 percentage points in 2015. Young adults ages 19 and 26 have a higher uninsured rate than other ages in the group likely due to Child Health Plus ending at age 19 and children losing coverage through their parents at 26. Among racial/ethnic groups, Latinos experienced the largest coverage gains although they continue to be the most likely to lack insurance.

Data from the American Community Survey shows higher uninsured rates in states that have not expanded Medicaid. In 2013, 19 states had uninsured rates of more than 14 percent. In 2015, only Alaska and Texas have uninsured rates that high and at the time data was collected neither had expanded Medicaid (Alaska’s Medicaid expansion went into effect September 2015).

Despite tremendous gains in the number of people covered by insurance, 29 millions Americans remain uninsured. States that have not expanded Medicaid should accept the federal dollars available to them to expand coverage for low-income residents of their states. For more details check out this report from the Commonwealth Fund.

Attention HWCLI Members and Partners!

Critical Follow-up to the CBO Planning Grant Application

Thanks to those of you who were able to attend this week’s CBO planning grant follow-up meeting.  For those of you who were unable to attend, I am happy to have a follow-up conversation about the next steps.

HWCLI is applying to lead our regional application for the NYS CBO Planning grant. The state will award each of 3 regional Consortia $2,500,000 for a one year planning initiative to support CBO infrastructure and capacity building in order to participate in the State’s Delivery System Reform Incentive Plan (DSRIP).

Our region includes the Island and  7 counties in Hudson area.

CBO participation in DSRIP, and in the ultimately transformed healthcare delivery system, is critical to ensure input from various communities, to implement  strategies to improve population and community health, and to address the determinants that influence health.

The purpose of the CBO planning grant is the development of financially sustainable infrastructure within community based organizations for value based contracting with performing provider systems.

The grant may only target CBOs that:

  • Have an annual budget of less than $5 million
  • Are not billing Medicaid or planning to bill Medicaid,
  • Are not directly providing health care services, and
  • focus on services to address the social determinants of health for the Medicaid and Medicaid eligible populations

We need your help!!

We are seeking:  Consortium Members.

If you are interested in being part of the regional consortium, please sign the attached MOU agreement and complete the following survey:


THIS SURVEY IS CRITICAL. IT WILL HELP TO ESTABLISH THE GOALS AND OBJECTIVES for our region, based on the information that you share. 

Please note we anticipate this survey to take 20-30 minutes.

I apologize in advance for the short notice, but we really need the surveys back by Tuesday, July 26th.  THANK YOU FOR YOUR WILLINGNESS TO PARTICIPATE and for your quick response.

Finally: Please plan to join our orientation webinar on Tuesday, July 26 at 10:30 a.m.

No registration is necessary and we’ll follow this message with an Outlook invitation.

Join WebEx meeting

Meeting number: 735 402 299

Join by phone
1-877-668-4493 Call-in toll-free number (US/Canada)
1-650-479-3208 Call-in toll number (US/Canada)
Access code: 735 402 299
Toll-free calling restrictions

The webinar will be a fast paced and highly informative overview— easily understood, interesting, and accessible whether you are well versed in the state’s reform efforts or totally new to the dialogue. It will contextualize the CBO Planning Grant within the context of the State’s goals for achieving and sustaining a system of health care financed by value based payment.

Our speaker, Josh Rubin from Health Management Associates, will:

  • address the national trend toward healthcare financing based on value and quality instead of volume (i.e. value based payment) and provide an overview of the goals for reform, nationally and within NYS
  • address the main elements of “accountable care” delivery and funding that underlie many NYS state initiatives, including the Delivery System Reform Incentive Plan (DSRIP) and explain what is behind changes to Medicaid funding
  • discuss how the resulting flexibility in addressing people’s needs can include flexibility to pay for CBO interventions and programs
  • describe the progression of options for healthcare financing that incentivize systems, like our Performing Provider Systems, to “do better more rapidly, in less traditional ways” and the potential for CBOs to contract directly with managed care providers as well as PPSs and others to do the kinds of things that are currently either under-resourced, lacking in the system, or available only where grants or contracts permit.
  • outline the core challenges faced by human service providers/CBOs in a value based payment system (i.e. the importance of knowing who is being served by the organization, being able to demonstrate need and document services, the importance of demonstrating evidence of CBO effectiveness, the capacity to support the cost of providing care, ability to understand and negotiate contracts, manage fiscal reporting, etc.)

We look forward to hearing from you via the survey and talking with you during the Q and A on Tuesday morning’s webinar.

We look forward to hearing from you!  Please contact us if you have any questions about this exciting opportunity to support our region’s most vulnerable communities.



Gwen O’Shea


HHS Issues New Medicaid Rules

On April 25, 2016, the Department of Health and Human Services (HHS) issued a final rule on managed care in Medicaid and the Children’s Health Insurance Program (CHIP). The rule, which is the first overhaul of Medicaid and CHIP managed care regulations in more than a decade, advances the Administration’s efforts to modernize the health care system to deliver better care, smarter spending, and healthier people.

The final rule has four key goals:

(1) Supporting states’ efforts to advance delivery system reform and improvements in quality of care for Medicaid and CHIP beneficiaries

The rules clarify states’ authority to enter into contracts that pay plans for quality or encourage participation in alternative payment models and other delivery system reform efforts.

(2) More consumer-friendly Medicaid health plan information

The rules require states to provide information such as the Medicaid handbook, plan provider directories, and other important enrollment information on one central website. It also supports providing enrollment assistance and counseling.

(3) New quality rating system

The rules would implement a quality star rating system for Medicaid Managed Care plans similar to the system currently used for Marketplace health insurance plans. This system will enable consumers to make choices based on plan quality. States and plans have 3 years to implement this provision.

(4) Steps to improving adequate health plan provider networks

States will be required to set time and distance standards for key provider types. Currently, whether to set such standards is completely up to the states. Requires plans to regularly update directories of doctors and hospitals. A 2014 investigation by the Department of Health and Human Services’ inspector general found that half the doctors listed in official insurer directories weren’t taking new Medicaid patients.

The provisions of the rule will be implemented in phases over the next three years, starting on July 1, 2017.

Statewide Survey: Community Engagement in DSRIP

Medicaid Matters New York (MMNY), the statewide coalition that advocates on the interests of Medicaid beneficiaries, is conducting a survey to assess the degree to which CBOs are engaged in DSRIP. A link to the survey can be found here, along with more background information about DSRIP.  More information about DSRIP is available here, and you can find out which DSRIP entity is active in your region using this map.

Community-based entities of any type, in any part of New York State, are encouraged to complete the survey. The survey results will be used to help MMNY assess what the needs are around the state for advancing community interests in local DSRIP regions. It will also allow MMNY to conduct state level advocacy to ensure that the DSRIP process engages CBOs in ways that recognize their strengths and address barriers to their participation.

DSRIP is a new health care payment and delivery system being implemented by New York State, which will impact how the State’s over six million Medicaid beneficiaries access health care services and how they experience care. All New Yorkers deserve access to high-quality care and the chance to experience good outcomes, including Medicaid beneficiaries. These significant changes, however, may disengage Medicaid beneficiaries from care if community-based organizations (CBOs) are not included in a meaningful way. Safety net providers and CBOs are rooted in low-income, underserved communities and have a trusted history of service to Medicaid beneficiaries.

Results of this survey will be shared only in the aggregate; individual responses to this survey will not be shared.