Implementing Health Reform. The Affordable Care Act (ACA) required the Centers for Medicare and Medicaid Services (CMS) by April 1, 2015 to review the benefits and cost-sharing in qualified health plans (QHPs) and certify that those plans offer benefits and cost-sharing that are at least comparable to those offered by the Children's Health Insurance Program (CHIP). In the event that a state experienced a shortfall in federal CHIP funding, CMS was to establish procedures for enrolling children in a QHP certified by HHS as comparable. On November 25, 2015, CMS finally released its certification.
CMS compared the second-lowest cost silver plan (SLCSP) in the largest rating area in each state to the CHIP benefits in that state. The review found that the average out-of-pocket spending in the SLCSP with financial assistance was higher than that for CHIP eligible children on a per-child basis in all states. The actuarial value of CHIP exceeded that of the SLCSP in all states except for Utah where they were equivalent. This means that families are expected to pay a higher percentage of expected health care costs in QHPs than in CHIP in all states except Utah. When premiums are taken into account, however, Utah's average out-of-pocket spending for the SCLSP was higher than CHIP.
The differences CMS found can be quite dramatic. In Washington state, for example, the plan actuarial value for the QHP was 48 percent while the actuarial value for the CHIP plan was 100 percent; premiums plus cost sharing for the QHP was $1969, for the CHIP plan $252.
CMS also found that the benefit packages in CHIP plans are generally more generous for child-specific services, such as dental, vision, or habilitation services, and for children with special health care needs than those offered by QHPs. CHIP coverage of core benefits such as physicians' services were similar between QHPs and CHIP.
HHS is not, therefore, certifying QHP services as equivalent to CHIP services. Congress has extended CHIP funding through 2017, and for the time being allotments provided to the states are sufficient to provide coverage for all targeted-low income children. Therefore CMS concluded no procedure was necessary at this time for enrolling children in certified QHPs, which is fortunate since no QHPs could be certified. The report is a warning, however, that if the CHIP program is allowed to expire after 2017, families can expect to receive less generous coverage thereafter.
CMS Issues Notices Regarding Information Requirements
CMS has in recent days been issuing a steady stream of paperwork reduction act notices relating to information it will be collecting or requiring insurers and health plans to provide under its recent benefit and payment parameters rule and final health insurance reform rule.
Recent notices published at the CMS paperwork reduction act website cover information that plans and insurers must provide enrollees regarding internal and external appeals; notices that health plans and insurers must provide enrollees with respect to lifetime limits, rescissions, and access to providers and emergency care; disclosure and record-keeping requirements with respect to grandfathered plans; revisions to the data collected to support QHP certification and exchange financial operations; information that must be provided for implementation and reporting for the quality rating system, enrollee satisfaction surveys, monitoring and appeals for survey vendors, and patient safety reporting standards for QHP insurers; and information that must be provided by third parties that pay QHP premiums and information that insurers must provide their enrollees as to display errors.
On December 1, 2015, CMS gave notice that it will be posting further notices on information collections relating to compliance with individual and group market reforms; the establishment of state exchanges and certification of QHPs; exchange standards for employers; and eligibility determinations regarding insurance affordability programs, exchange enrollment, Medicaid, and CHIP.
CMS Releases Quality Improvement Strategy Guidance
On November 5, 2015, the Centers for Medicare and Medicaid Services (CMS) released its Quality Improvement Strategy (QIS): Technical Guidance and User Guide for the 2017 Coverage Year, a QIS Implementation Plan and Progress Report Form, and a summary of its 2017 QIS requirements.
Under the Affordable Care Act (ACA), an insurer participating in the marketplace for two or more consecutive years must implement and report on a QIS. For 2017 qualified health plan (QHP) insurers must submit a QIS if they 1) offered individual or SHOP marketplace coverage in 2014 and 2015; 2) provide family and/or adult-only coverage and 3) had more than 500 enrollees in a product type as of July 1, 2015. Each eligible QHP in a product type with more than 500 marketplace enrollees must be included in a QIS. Child-only, standalone dental plans, or QHPs compatible with health savings accounts are not subject to QIS requirements and enrollees in these types of plans should not be counted towards calculating minimum enrollment numbers. Insurers that did not issue QHPs until 2015 do not have to implement a QIS until 2018.
All eligible insurers must implement a payment structure that provides increased payment or other market-based incentives for improving health outcomes for plan enrollees. This could include increased payments, bonuses, or noncash resources to providers that meet quality performance targets or providing financial incentives to enrollees who seek preventive services, seek "high-value" providers, access nutritional counseling, or exhibit other behaviors associated with improved health.
Insurers must in addition implement a QIS that includes at least one of the following:
- Activities for improving health outcomes,
- Activities to prevent hospital readmissions,
- Activities to improve patient safety and reduce medical error,
- Activities for wellness and health promotion; or
- Activities to reduce health and health care disparities.
All QIS activities must be linked to an incentive, but population- or community-based activities may meet the QIS standard if they are linked to an incentive. QHP insurers must also adhere to the 2017 Guidance and User Guide requirements and report periodically to the applicable marketplace.
A QHP insurer can implement and report on one QIS that covers all of its QHPs or implement more than one QIS if having just one QIS would not address all of its QHPs. All QHPs must be covered by a QIS. QHP insurers may submit a QIS that addresses a subpopulation of its enrollees in a particular QHP, however, for example a QIS addressing the specific needs of diabetic enrollees. Insurers must use data to identify and describe the health outcome needs and priorities of its enrollees or of a subgroup of enrollees.
QHP insurers must submit their 2017 QIS plan for approval during the 2017 QHP plan submission window in April and May 2016. Part of this submission may be made public but some of the information will be regarded as confidential and proprietary. The QIS will be evaluated by the federally facilitated marketplace (FFM) or relevant state marketplace (SBM) between May and August 2016. The insurer will be sent one or more correction notices if the QIS does not meet program requirements.
CMS will evaluate all QIS submissions for insurers applying to issue QHPs in the FFM. States performing plan management functions in the FFM will also evaluate QIS submissions. SBMs will evaluate QHPs in their marketplaces using their own standards, with the federal standards serving as a minimum. The Office of Personnel Management will evaluate QIS submissions for multistate plans. The final 2017 QIS approval for 2017 plans will be issued in September of 2016 with implementation beginning on January 1, 2017.
Insurers must report annually on the progress of their QIS. In future years, insurers will be able to continue their QIS as is, modify it, or submit a new QIS. CMS urges insurers to leave their QIS implementation plan in place for at least two years before modifying it or submitting a new one to allow time to see if it is working as expected. But insurers must submit a new QIS if their change their QIS topic area or incentive type, they meet their performance target, or their QIS results in negative outcomes or unintended consequences. At this time, an insurer will not be required to demonstrate that its QIS actually resulted in improvement, but it is required to track progress and make adjustments as appropriate.
from Health Affairs Blog http://ift.tt/1HENIpS
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