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Vorys Health Care Advisors

 
For health care reformers, the challenge is to improve care quality and expand access to providers and services while controlling costs. It is not a job for the timid. Instead, it requires creativity, experience and leadership. Vorys Health Care Advisors’ strategic solutions and guidance exemplify each of these imperatives. Our health care and Medicaid consultants help providers, business decision makers, state and federal government agencies and professional associations respond to the complex needs of health care consumers by discovering, developing and implementing innovative policies and programs.

Federal Budget Agreement Delays Medicaid DSH Cuts

Posted in Affordable Care Act, Medicaid

Section 1204 of the federal budget agreement, HJ.Res.59, delays the Medicaid Disproportionate Share Hospital (DSH) payment reductions included in the Affordable Care Act (ACA) for two years.  As originally contemplated in the ACA, the DSH reductions were to have become effective in October 2013.  Instead, the budget agreement delays the reductions until October 1, 2015, but doubles the reduction that would otherwise have applied in that year.  In light of the delay, the Centers for Medicare & Medicaid Services has indicated that it will publish updated fiscal year 2014 DSH allotments in the Federal Register early next year.

The budget agreement was recently passed by Congress and signed by the President on December 26th.

Ohio Supreme Court Upholds Medicaid Expansion

Posted in Behavioral Health, Medicaid

The Ohio Supreme Court issued a decision today confirming the constitutionality of the state’s decision to expand the Medicaid program through an action of the Controlling Board.  The Court rejected a constitutional challenge made by six legislators.

In November, our colleagues at Vorys, Sater, Seymour and Pease filed an amicus brief on behalf of Advocates for Ohio’s Future, the Coalition for Healthy Communities, the National Alliance on Mental Health, the Ohio Association of County Behavioral Health Authorities, the Ohio Council of Behavioral Health and Family Services Providers and the Ohio Provider Resource Association urging the Court to uphold the Controlling Board’s decision as constitutional.

Today’s decision ensures that an estimated 275,000 of Ohio’s most vulnerable citizens will have access to health care.

To read the decision, click here.

CMS Announces Extension of Stage 2 Meaningful Use

Posted in Uncategorized

The federal Centers for Medicare & Medicaid Services (CMS) announced on Friday that Stage 2 meaningful use for the Medicare and Medicaid EHR (electronic health record) Incentive Programs will be extended through 2016, and Stage 3 will not begin until at least fiscal year 2017 for hospitals and calendar year 2017 for physicians and other eligible professionals that have by then completed at least two years at Stage 2.

As reported by the U. S. Department of Health & Human Services’ Health IT Buzz, a statement by Robert Tagalicod, director, Office of E-Health Standards and Services, CMS, and Jacob Reider, M.D., acting national coordinator for health information technology for the Office of the National Coordinator for Health Information Technology (ONC), said that there are two goals of this change: (1) to allow CMS and ONC to focus on the successful implementation of the enhanced patient engagement, interoperability, and health information exchange requirements in Stage 2; and (2) to utilize data from Stage 2 participation to inform policy decisions for Stage 3.

Meaningful use is the set of standards defined by the CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.  The goal of meaningful use is to promote the spread of electronic health records to improve health care in the United States.

Meaningful use is spread out over three stages.  The phased approach helps providers move from creating information in Stage 1, to exchanging health information in Stage 2, to focusing on improved outcomes in Stage 3.  The requirements for meeting each stage of meaningful use is available on CMS’ website.

The proposed rules for the requirements providers must meet for Stage 3 are expected to be released in the fall of 2014.  A separate rule extending Stage 2 by a year is expected sooner.

Vorys Attorney Discusses Confusion About Whether the Anti-Kickback Statute Applies to Qualified Health Plans

Posted in Affordable Care Act

Vorys attorney Robin L. Canowitz recently published an alert discussing potential confusion between a letter released by the U. S. Department of Health and Human Services (HHS) and a memo published a week later by the Centers for Medicare & Medicaid Services (CMS).  In the letter, HHS clarifies that qualified health plans sold in health insurance marketplaces are not “federal health care programs”.  As such, the federal Anti-Kickback Statute (AKS) does not apply.  As Robin explains, providers were concerned that the AKS would prohibit them from paying for the premiums of individuals enrolled in qualified health plans through the marketplace.  The letter clarifies that providers can legally pay premiums for patients enrolled in a qualified health plan without violating the federal AKS.  The memo issued by CMS just a week later, however, indicates that HHS has concerns with this practice.

Read Robin’s alert for a thorough discussion of these issues.

The Impact of the ACA on the Health Insurance Market – By the Numbers

Posted in Affordable Care Act, Health Care Reform

On a recent MSNBC segment, Steve Rattner shared the following slides that illustrate ways in which the health insurance market will be impacted as a result of the Affordable Care Act (ACA).

The first reflects how various populations will be affected by the individual mandate to have insurance.
Who will pay more under Obamacare?

The second indicates that most Americans who purchase individual plans — including those plans that the President recently announced may be continued depsite noncompliance with ACA requirements — only stay on those plans for a relatively short period of time before moving on.
Short Stays on Individual Plans

The third shows how coverage is projected to shift as a result of the ACA.
Shift in Coverage Under Obamacare

What does the President’s announcement about continuing canceled health insurance policies really mean?

Posted in Affordable Care Act

Responding to the concerns of many Americans regarding a potential cancellation of some health insurance policies, President Obama announced on Thursday that insurance companies can continue to offer for another year some health plans to individuals, families, and small businesses that do not meet the Essential Health Benefits requirements established under the Affordable Care Act (ACA).

As we reported in a recent blog post, beginning in 2014, Medicaid plans and small group and individual plans sold inside and outside of the Health Insurance Marketplace must cover a package of 10 categories of items and services known as Essential Health Benefits (EHBs).  These categories include:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental and/or substance use disorder services, including treatment of behavioral disorders
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

The President’s announcement was spurred by some individuals receiving cancellation notices for health insurance policies they currently have.  These are plans that will not meet EHB requirements.

  • The policies at issue are individual and family policies purchased directly from insurers.
  • Consumers covered by Medicaid, Medicare, or large employers are unaffected.
  • The administration is also allowing extension of small-employer plans that do not meet EHB requirements.
  • Qualified health plans sold in the Marketplace must continue to cover EHBs.

The policy change will allow insurers to extend these existing “noncompliant” plans for one more year for current customers.  Policies renewing before the end of this year will last until late 2014 and policies that expire in 2014 can extend into 2015.  If carriers do renew, they must disclose to the policyholder differences between the benefits offered in their existing plan and those EHBs required by the ACA.  In other words, why the policy is “noncompliant” with the EHB requirements.

As reported by The Washington Post:

Individual policies have long been a problematic part of the insurance market, with higher prices than most group plans, fewer benefits and a tendency to cut off people when they get sick. The health-care law tried to address this problem by directing Americans who rely on individual policies to buy coverage through the new insurance marketplaces — and by defining the set of essential benefits.

Despite the policy change, the administration is allowing each state to determine whether its residents can renew a plan that does not comply with the ACA’s EHB requirement.  Some states, including Washington, have already announced that they will not allow noncompliant health insurance policies to be sold to their residents.  Other states, such as Florida, have announced that they will allow noncompliant insurance plans to be renewed for their residents.

Additionally, an insurance company is not required to renew its noncompliant policy.  So although a consumer may want to renew a policy that will not cover EHBs, the state may not allow it and/or the insurance company itself may not continue the policy.  Consumers should check with their state to see if it will allow renewal of noncompliant plans.  They should also check with their insurer to see if it will be renewing canceled policies.

Even if the state and the insurance company will allow the renewal of a noncompliant plan, consumers should evaluate alternatives offered in the Marketplace to see if qualified health plans sold there offer better coverage at equal or better price.

Remember that individuals earning between 100% and 400% of the federal poverty level (FPL) ($23,550 to $94,200 for a family of four) will have access to premium tax credits in order to make purchasing insurance in the Marketplace more affordable.  Additionally, individuals earning between 100% and 250% FPL  ($23,550 and $58,875 for a family of four) will have access to cost-sharing subsidies that will bring down their deductibles, copayments, and coinsurance.  By contrast, noncompliant plans are not eligible for subsidies.

In summary, while you may now be able to keep your plan that does not include EHBs, when you compare plans in the Marketplace, you may find that you will get an equal or better price for a better benefit than what you have now.

Mental Health Parity Requirements and Medicaid

Posted in Behavioral Health, Medicaid

The U. S. Department of Health and Human Services announced on Friday final regulations implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).  The MHPAEA is intended to align insured health care benefits for mental and substance use disorders (M/SUD) with those for medical and surgical care.

The MHPAEA requires certain group health plans to ensure that financial requirements (e.g., copays and deductibles) and treatment limitations that are applicable to M/SUD benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits.  The MHPAEA does not mandate that a plan must provide M/SUD benefits.  Rather, it requires that if a plan provides medical, surgical, and M/SUD benefits, it must provide them in an equitable fashion.

The MHPAEA supplements the provisions that were included in the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits.  The MHPA did not, however, apply to substance use disorder benefits; MHPAEA continues the MHPA parity rules for mental health benefits and extends them to benefits for substance use disorders.

Importantly, these final regulations apply to group health plans and health insurance issuers, but they do not apply to Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), or the Children’s Health Insurance Program (CHIP).  However, MHPAEA requirements are incorporated by reference into statutory provisions that do apply to those entities.  On January 16, 2013, the Centers for Medicare & Medicaid Services (CMS) released a State Health Official (SHO) letter regarding the application of the MHPAEA requirements to Medicaid MCOs, ABPs, and CHIP.  In this guidance, CMS adopted the basic framework of MHPAEA and applied the statutory principles as appropriate across these Medicaid and CHIP authorities.  The letter essentially says the following –

  • Alternative benefit plans – including those for Medicaid expansion populations – must meet MHPAEA requirements.
  • MHPAEA applies to CHIPs, regardless of whether the CHIPs operate through a managed care or fee-for-service system.  Also, to the extent the CHIP provides full coverage of the early periodic screening, diagnosis, and treatment (EPSDT) Medicaid benefit, it is deemed to have met the parity requirements.
  • Parity requirements apply to MCOs that contract with a state Medicaid program to provide both physical and behavioral health benefits.  The letter specifically indicates the following:

In light of Medicaid regulations that direct states to reimburse MCOs based only on state plan services, CMS will not find MCOs out of compliance with MHPAEA to the extent that the benefits offered by the MCO reflect the financial limitations, quantitative treatment limitations, nonquantitative treatment limitations, and disclosure requirements set forth in the Medicaid state plan and as specified in CMS approved contracts.  However, this does not preclude state use of current Medicaid flexibilities to amend their Medicaid state plans or demonstrations/waiver projects to address financial limitations, quantitative treatment limitations, nonquantitative treatment limitations, and disclosure requirements in ways that promote parity.  Any additional or alternative treatment limitations put in place by the MCO, however, must comply with mental health and substance use disorder parity requirements.

What this all means is that, although the final regulations do not technically apply to ABPs, CHIPs, and MCOs, they essentially do to the extent described in the SHO letter.  The letter also states that CMS intends to issue additional guidance that will assist states in their efforts to implement the MHPAEA requirements in their Medicaid programs.

17 Million Americans to Qualify for Premium Tax Credits; Ohio Has Eighth Most Eligibles

Posted in Affordable Care Act

A new report released by the Kaiser Family Foundation indicates that about 17 million Americans who are currently uninsured or who buy insurance on their own will be eligible for premium tax credits to buy health insurance in the health insurance marketplace beginning in 2014.  As we have discussed in other posts, beginning in 2014, individuals with incomes between 100% and 400% of the federal poverty level ($11,490 to $45,960 for an individual and $23,550 to $94,200 for a family of four) will have access to premium tax credits that will lower the amount of premium they pay for coverage.

Some highlights from the report include the following:

  • Three states (Texas, California, and Florida) each have more than 1 million tax-credit-eligible residents
  • Another seven states have more than 500,000 tax credit-eligible residents.
  • Ohio has the eighth most tax credit-eligible residents, at 544,000 individuals.
  • At the lower end, seven states have fewer than 50,000 tax credit-eligible residents, with the District of Columbia (9,500) and Vermont (27,000) having the fewest.
  • The five states with the most tax credit-eligible individuals account for about 40% of all such individuals nationally.

To conduct the analysis, Kaiser used data from the 2012 and 2013 Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC).  They started with a pool of individuals who have no insurance or who purchase insurance on their own.  Kaiser then looked at these individuals’ family incomes under Affordable Care Act rules and the premiums they would face to determine whether they would qualify for a premium tax credit.  Lastly, Kaiser removed approximately 16% of potential eligibles because research shows that some people who are uninsured or purchase insurance themselves have access to employer-based coverage, either through an offer from their own employer or through an offer through a spouse or parent.  Those that remain represent Kaiser’s estimate of tax-credit eligible individuals.  A more complete description of the analysis may be found in the report.

 

Recent Study Concludes That Poverty Affects Childhood Brain Development

Posted in Behavioral Health

A study recently published in JAMA Pediatrics indicates that exposure to poverty in early childhood materially impacts brain development.  The study also found that “some of the negative effects on the brain…can be mediated by the level of support or hostility of the children’s caregivers, as well as the level of stressful events in life.”

Additional media commentary on the study can be found on these various sites: Bloomberg, CBS NewsU. S. News & World Report, MedPage Today, and Reuters.

Scrutton Named Vice-Chair of AHLA Behavioral Health Task Force

Posted in Behavioral Health

Vorys, Sater, Seymour and Pease is pleased to announce that Suzanne Scrutton, a partner in the Columbus office and a member of the health care group, has been named a vice-chair of the American Health Lawyers Association (AHLA) Behavioral Health Task Force. The newly formed Task Force will advance the understanding of laws impacting behavioral health, including the delivery of services to those living with mental illness, certain neurological conditions, substance use disorders, or developmental disabilities, and reimbursement for such services.

Read this press release for additional details about Ms. Scrutton’s responsibilities and the role of the Task Force.