National Academy of Medicine outlines strategies for high-need patients

On July 6, 2017, the National Academy of Medicine released a valuable report entitled, “Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health.” The report describes key characteristics of high-need patient populations, tools that can be adopted to identify evidence-based models of care for them, and strategies to promote successful implementation of such models in collaboration with a broad range of stakeholders at the federal, state, and community level. It stresses the importance of behavioral health issues, social determinants of health, and community-based supports for high-need patients who often struggle at home with functional limitations associated with aging, disabilities, and a wide range of long-term diseases examined in the report. [More]

Update on the Senate’s efforts to Repeal parts of the ACA

After releasing the Better Care Reconciliation Act at the end of last week, leadership in the U.S. Senate announced this week that it will not be voting on the bill before the July 4th Congressional recess as planned. Instead efforts are underway to overhaul the bill, with a vote is expected sometime after the recess. Senate Majority Leader Mitch McConnell has said that he intends to submit a new version of the bill to be scored by the Congressional Budget Office today. [More]

Centers for Medicare and Medicaid Services Awards PCG Quality Improvement Organization-like Certification

Boston, MA, June 16, 2017 – Public Consulting Group (PCG) is pleased to announce its certification as a Quality Improvement Organization-like (QIO-like) entity by the Centers for Medicare and Medicaid Services (CMS). Already a champion of improvement to the nation’s healthcare system, this new certification will further enable PCG to work to enhance the quality and cost efficiency of care for Medicare and Medicaid beneficiaries. [More]

Section 1332 State Innovation Waiver – Recent developments and the newly-released checklist

In follow-up to its letter to Governors regarding the Section 1332 Waiver opportunity, the Centers for Medicare and Medicaid Services (CMS) and the Department of Treasury released a Section 1332 checklist on May 16 designed to help states pursue ACA State Innovation Waivers. Section 1332 of the ACA allows states to waive specific ACA provisions as long as they apply according to the process set out in regulations and meet the following comparability requirements:

• The waiver will provide coverage to at least a comparable number of the state’s residents as would be provided without the waiver;
• The waiver will provide coverage and cost-sharing protections that are at least as affordable as would be provided without the waiver;
• The waiver will provide for coverage that is at least as comprehensive as would be provided without the waiver; and
• The waiver will not increase the federal deficit. [More]

21st Century Cures Act

On December 7, 2016 Congress passed the 21st Century Cures Act (the “Act”), which was signed into law on December 14, 2016. The Act is aimed at modernizing health care delivery, improving quality and targeted improvements in the area of cancer treatment, mental health care, opioid addiction, and other focused areas. One such modernization effort requires states to implement Electronic Visit Verification (EVV) systems for personal care services and home health care services providers by 2019 and 2023, respectively. These EVV systems will help ensure that beneficiaries receive the care that is being billed to Medicaid. Additionally, the Act allocates over $1 billion in grant funding over the next two years for states to combat the opioid epidemic. States began the application process for grant funds in early 2017, and efforts are now underway in a number of states to implement new programs and services focused on treatment and prevention. Below we highlight one way PCG has identified to leverage existing claims data to implement reforms. This Act is largely funded through the Prevention and Public Health fund established in the Affordable Care Act (ACA). For more information on additional modernization and reform elements of the Act, please click here. [More]

Massachusetts Supreme Judicial Court holds that the retention of the right to live in a home transferred to an irrevocable trust does not render the home an “asset” for Medicaid purposes

On May 31, 2017, the Supreme Judicial Court of Massachusetts reversed and remanded two cases involving determinations of eligibility for long-term care assistance under the Massachusetts Medicaid program (MassHealth). Nadeau v. Director of the Office of Medicaid and Daley v. Secretary of the Executive Office of Health and Human Services, SJC 12200 and 12205, May 31, 2017. [More]

CBO estimates that AHCA would severely increase the number of uninsured persons

On May 24, 2017, the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) released estimates on the impact of the proposed H.R. 1628, the American Health Care Act of 2017 (AHCA), as passed by the U.S. House of Representatives on May 4, 2017. AHCA would partly repeal the Affordable Care Act (ACA). The CBO estimates that AHCA would severely increase the number of persons without health coverage, as compared to the ACA... [More]

States seek to intervene in House v. Price lawsuit

On May 18, 2017, 15 states and the District of Columbia filed a motion to intervene in House v. Price, a lawsuit threatening the availability of federal funds (about $9 billion in 2017) for cost-sharing reduction (CSR) payments to health insurers under the Affordable Care Act (ACA). The lawsuit pertains to whether or not CSR payments are subject to annual Congressional appropriations. It was initially filed in November 2014 in U.S. District Court, which ruled in favor of the U.S. House of Representatives in May 2016, but held its decision in abeyance pending appeal. It is now before the U.S. Circuit Court of Appeals in the District of Columbia. [More]

Medicaid Member Engagement: One Size Does Not Fit All

There’s a certain catch-phrase going around related to Medicaid members: they need to have “skin in the game.” This phrase seems to imply that individuals receiving Medicaid are somehow different than other individuals—those who have private insurance—but they’re not. Individuals receiving healthcare through Medicaid are just like you and me. They want their children to be healthy and happy. They want to improve their health. They want to live happy and productive lives. However, due to life circumstances, some of them may need a little more assistance than others in understanding the role they play in their healthcare. Effective member engagement can help guide individuals through the complex Medicaid system of care. Medicaid’s population is very diverse and serves individuals from different socioeconomic backgrounds—the aged, blind, disabled, children, pregnant women, relatives taking care of children, and childless adults can qualify for Medicaid if they meet state specific guidelines. Activities to engage Medicaid members in their healthcare need to be as diverse as the population. Mass mailings to the entire population may not be as effective as specific information targeted to a select group of individuals. [More]

New ACA-Related announcements from the Federal Administration

The administration is taking more limited steps to influence implementation of the law, including two upcoming changes to enrollment through Marketplaces announcements last month. On May 15, the Centers for Medicare and Medicaid Services (CMS) announced that it will be proposing a rule to have enrollment into Federally-facilitated Small Business Marketplace (known as Small Business Health Options Program or “SHOP”) health insurance plans go directly through insurers as of 2018. Two days later, on May 17, CMS released guidance enabling (but not requiring) full direct enrollment in individual market Federally-facilitated Marketplace (FFM) plans starting for open enrollment for plan year 2018. [More]