The Lowdown from Up on the Hill

A bi-weekly newsletter featuring the latest federal policy news on exchanges, healthcare IT and Medicare/Medicaid

The Lowdown from Up on the Hill is produced by Altegra Health’s government relations team to highlight federal public policy news pertinent to our partners in the areas of exchanges, healthcare IT and Medicare/Medicaid. Get The Lowdown delivered right to your inbox by filling out the form in the right column. Subscribe today!

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July 2016

Government Relations Updates

About the Government Relations Team

For more information on our Government Relations team please visit our website. If you have any questions or would like additional information, please contact Tim Jones, Director of Federal & State Government Relations.

Archive: Public Policy News 2015


  • Congress reaches deal to fund government On December 15, Congress reached an agreement to enact legislation providing government funding for the rest of FY 2016, which ends on September 30, 2016. The legislation includes $3.67 billion for CMS management and operations, which is equal to the 2015 enacted level. The legislation would delay the health insurance excise tax through calendar year 2017; would delay the "Cadillac tax" on high-benefit health plans through calendar years 2018-19; and would delay the medical device tax through calendar year 2017. The legislation was passed by the House, the Senate, and signed into law by President Obama.
  • ACAP submits comments on 2017 insurance exchange benefits proposed rule On December 21, ACAP sent a letter to CMS regarding the proposed 2017 benefits rule for the insurance exchanges. Regarding risk adjustment, ACAP is concerned by CMS' proposal to incorporate preventive services; however, it supports the inclusion of pharmacy data.
  • CMS releases updated insurance exchange enrollment statistics On December 22, CMS released updated enrollment statistics in the insurance exchanges. Since November 1, more than 8.2 million signed up for health coverage through the federal exchange website or had their coverage automatically renewed - with millions more selecting plans through the state exchanges. The announcement includes state-by-state enrollment statistics.

  • Cigna CEO interviewed about insurance exchange participation On December 7, an interview with Cigna CEO David Cordani noted that Cigna plans to offer plans in the insurance exchanges in the future despite the business's lack of profit. Cordani recommends that plans be given more flexibility to design benefits to meet consumer needs.
  • Andy Slavitt discusses insurance exchanges On December 8, CMS Acting Administrator Andy Slavitt testified before the House Energy and Commerce Committee. During the hearing, Slavitt said the state insurance exchanges are currently financially viable. Slavitt detailed the federal funding for the state exchanges will end moving forward.


  • MACPAC appoints new commissioners On December 16, the GAO announced the appointment of seven new members to MACPAC. New commissioners include representatives of Truven Health Analytics, the former head of California Medicaid, and Tufts Health Plan, among others. Sara Rosenbaum, a current commissioner, will serve as the Commission's Chair.
  • Michigan Medicaid expansion plan continues On December 17, CMS approved Michigan's Medicaid expansion. The plan requires participants work with their physicians on strategies to lose weight, quit smoking or adopt other healthy behaviors. Approval of the second waiver was required by state law before December 31 for the program to continue.
  • Senate Finance Committee releases MA chronic care paper On December 18, the Senate Finance Committee released a paper detailing policies being considered as a part of the committee's effort to improve how Medicare treats beneficiaries with multiple, complex chronic illness. The paper organizes policies into several key areas under consideration, including allowing MA plans to provide care improvements and/or wellness programs specifically tailored for a chronic condition. Additionally, the paper is soliciting input on the criteria that could be used to determine what new supplemental benefits could be offered by a MA plan, including those addressing non-medical, social services.

  • NAMD sends CMS letter supporting MA risk adjustment model proposal On November 24, NAMD sent a letter to CMS supporting its proposal to revise the structure of the MA risk adjustment model to address the under-prediction of costs, including the proposed six tiers. NAMD also supports ongoing CMS analysis and refinement of the updated HCC risk model to improve accuracy of costs for certain conditions and subpopulations of the dual eligible population.
  • MHPA sends CMS letter supporting MA risk adjustment model proposal On November 25, MHPA sent a letter to CMS supporting its proposal to revise the structure of the risk MA risk adjustment model to address the under-prediction costs, including the proposed six tiers. MHPA supports extending the call letter comment period and notes the problems using a concurrent model and determining dual eligible status.
  • CMS releases September 2015 Medicaid enrollment report On November 30, CMS releases the September 2015 Medicaid enrollment report. Nearly 71.6 million individuals were enrolled in Medicaid and CHIP in September 2015. The report contains state-by-state enrollment statistics.
  • MACPAC releases annual Medicaid and CHIP data book In December, MACPAC released its Medicaid and CHIP data book. The data book contains state-by-state enrollment statistics, including enrollment in Medicaid MCOs and by dual eligible status. The data book profiles state Medicaid administrative spending on eligibility and enrollment.
  • CMS releases Medicaid enhanced funding final rule On December 3, CMS released its final rule extending Medicaid federal matching rates for the design, development, installation, or enhancement of Medicaid eligibility and enrollment systems. As part of the rule, CMS noted Altegra Health's letter sent on the proposed rule recommending that states enhance their systems to more efficiently process MSP applications. CMS responded that it considered these comments to be outside of the scope of this rule; however, it will take these comments into consideration.
  • Congressional committees concerned about Medicaid asset verification On December 7, the House Energy and Commerce Committee and Senate Finance Committee Chairman sent a letter to CMS regarding its oversight of states' implementation of electronic asset verification systems for aged, blind, and disabled (ABD) populations under Medicaid. The letter cited a 2008 law that requires states to implement electronic asset verification systems to verify the assets of ABD Medicaid applicants.
  • ACAP sends CMS letter on Star ratings On December 9, ACAP sent CMS comments about proposed changes to the 2017 Star ratings. ACAP recommends that CMS share more details about the interim measures to address the correlation between socio-economic factors and quality scores in advance of the 2017 Advance Notice.

Notable Public Policy and Advocacy Efforts

On November 25,

Altegra Health sent a comment letter to CMS on the HPMS memo dated October 28, “Proposed Changes to the CMS-HCC Risk Adjustment Model for Payment Year 2017.” The letter details Altegra Health’s concern about the changes CMS proposes to the partial-benefit dual eligible model that could have the unintended consequence of reducing enrollment in Medicare Savings Programs. Download the Altegra Health Comment Letter:
Altegra Health Comment Letter


  • Experts weigh government action to address insurance exchange viability This article notes possible CMS action to address health plan concerns about the viability of the insurance exchanges. Because UnitedHealthGroup expressed concerns about continuing to sell in the exchanges, most experts believe CMS will work to address health plan concerns to avoid political fallout during the 2016 election.
  • CMS releases 2017 proposed payment notice On November 20, CMS released the proposed annual Notice of Benefit and Payment Parameters for 2017. To meet the sequestration requirement for the risk adjustment program for fiscal year (FY) 2016, HHS will sequester risk adjustment payments made using FY 2016 resources in all States where HHS operates risk adjustment at a sequestration rate of 7.0 percent, which will be paid in FY 2017. CMS proposes to continue to use the same risk adjustment methodology finalized in the 2014 Payment Notice.

  • Kaiser Family Foundation releases analysis of insurance exchange competition On November 3, the Kaiser Family Foundation released an analysis of health plan participation in the 2016 insurance exchanges. KFF found that 40 percent of counties in states using the federal exchange website will have just one or two insurers, up from 35 percent of counties in 2015. KFF also found that the number of counties with 5 or more insurers decreased in 2016.
  • CMS announces enrollment statistics for the week insurance exchanges open enrollment On November 12, CMS announced that over 543,000 had selected a health plan during the first week of open enrollment in the insurance exchanges, of which 34 percent of the population is new enrollees.


  • ACAP releases study of Medicaid churn On November 3, ACAP released a paper finding that the average person enrolled in Medicaid receives benefits, on average, for just 9.7 months of the year. According to the paper, this discontinuity in care owes itself largely to “churn.” This cycle of enrollment and dis-enrollment leads to poorer health, results in higher-cost episodes of care, and frustrates the efforts of providers and others to deliver top-quality health care.
  • MHPA releases report about Medicaid On November 12, MHPA released a report, "The Still Expanding State of Medicaid in the United States," which gives a view of the Medicaid market, its growth potential, and assesses the continuing effect of Medicaid expansion. Noteworthy results in the data: unprecedented growth in Medicaid with 1 in 20 Americans added to Medicaid in the past two years and a large increase in Medicaid managed care penetration. Another noteworthy trend noted in the report is consolidation in the Medicaid managed care industry: of the 194 private Medicaid plans serving Medicaid beneficiaries in 2015, the largest 12 plans collectively have 56 percent of that total membership.
  • Senate Finance Committee seeks input on Medicaid On November 13, the Senate Finance Committee sent a letter to Medicaid stakeholders seeking input on improving the quality, efficiency, transparency and accountability of the program. Specifically, the committee asked for information on how state reporting requirements can be streamlined to reduce redundancies and provide useable, timely information that will help the states and federal government fulfill their respective administrative and oversight responsibilities. The letter was sent to NAMD, MACPAC, MHPA, and ACAP, among other stakeholders.
  • MedPAC comments on MA CMS-HCC model proposed changes On November 16, MedPAC sent a letter to CMS commenting on the October 28 HPMS memo outlining proposed changes to the MA CMS-HCC risk adjustment model. The letter commends CMS for acknowledging past MedPAC data identifying under-predicted costs for full dual eligibles and over-predicted costs for partial dual eligibles.
  • CMS releases Medicaid enrollment and expenditure data In November, CMS released Medicaid enrollment data as part of its Medicaid expenditure reporting through the Medicaid Budget and Expenditure System (MBES). The enrollment information is a state-reported count of unduplicated individuals enrolled in the state’s Medicaid program at any time during each month in the quarterly reporting period. The enrollment data identifies the total number of Medicaid enrollees and, for states that have expanded Medicaid, provides specific counts for the number of individuals enrolled in the new adult eligibility group, also referred to as the “VIII Group”.

  • Montana to implement ACA Medicaid expansion On November 2, Montana announced that it has received CMS approval to expand Medicaid. Coverage is offered through a private insurance company (Third Party Administrator), following the model of the successful Health Montana Kids health care program. Residents can apply now for the new program that will begin in January.
  • HHS OIG releases FY 2016 workplan On November 2, the HHS OIG released its FY 2016 workplan. Among other subjects, the HHS OIG will examine CMS's oversight of MA encounter data validation; MA risk adjustment data and the sufficiency of documentation supporting diagnoses; and MA operation in Puerto Rico.
  • House committee creates Medicaid task force On November 5, the House Energy and Commerce Committee announced the creation of a Medicaid Task Force to "strengthen and sustain the critical program for the nation's most vulnerable citizens."
  • CMS announces additional dual demonstration in New Yorks On November 5, CMS announced that New York will offer an additional dual eligible demonstration. This partnership will create a program demonstration known as Full Integrated Duals Advantage for Individuals with Intellectuals and Developmental Disabilities (FIDA-IDD) that will focus on these individuals' long-term care needs. New York and CMS are working with Partners Health Plan to offer this FIDA-IDD program in New York City, Long Island, and Rockland and Westchester Counties; it is expected to begin on April 1, 2016.
  • ACAP sends letter of support for MA risk adjustment model changes for dual eligibles On November5, ACAP sent a letter to CMS in support of a recent memo proposing to change the MA risk adjustment model's methodology for dual eligibles. The letter notes, "Improving the accuracy of Medicare risk-adjustment for full-benefit dual eligible will help D-SNPs and MMPs become more sustainable."
  • CMS announces no changes to Part B premium for majority of Medicare beneficiaries On November 10, CMS announced that the Medicare Part B premium will not change for those not impacted by recent federal legislation that prevented at least a 50 percent increase for the dual eligible and other smaller populations.


  • CMS releases statistics about CMS releases statistics about federal insurance exchange open enrollment federal insurance exchange open enrollments On October 26, CMS released new data from HHS indicating that, in 2016, nearly 80 percent of returning insurance exchange enrollees will be able to buy a plan with premiums less than $100 month after tax credits. Across the federal exchange in the 37 states, the cost of the benchmark plan will increase an average of 7.5 percent. For 2016, over 66 percent of counties will have three or more issuers.

  • CMS announces early reinsurance payments On October 9, CMS announced that it will make an early payment under the transitional reinsurance program for the 2015 benefit year to issuers of reinsurance-eligible plans. CMS anticipates making this early payment in March 2016. Reinsurance funds not paid out through this early payment be paid out late 2016, as a part of the standard reinsurance data submission, validation, calculation, and payment process.
  • Co-ops struggling to remain financially viable This article highlights the financial struggles of co-ops established through the ACA. Recently, CMS sent warning letters to 11 co-ops that they will be placed in "enhanced oversight" or were required to produce a plan of "corrective action." Amid this increased monitoring, one co-op has folded and four others are preparing to close in late December as of the date of the article.
  • Kaiser Family Foundation releases analysis of uninsured population On October 13, the Kaiser Family Foundation released an analysis with national and state-by-state estimates of eligibility for ACA coverage options among those who remained uninsured.
  • HHS projects insurance exchange enrollment On October 15, HHS Secretary Burwell announced that she will expect 10 million individuals to be enrolled in coverage through the insurance exchanges and paying their premiums at the close of 2016. Additionally, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a demographic of the uninsured individuals who are likely eligible for the exchange. According to the reports, nearly 8 in 10 of the approximately 10.5 million uninsured individuals likely to be eligible for the qualified health plans (or the "QHP-eligible uninsured") may be eligible for financial help through the exchange.

  • Health IT

  • Health Partners announces results of program targeting pregnant moms On October 28, Health Partners Plans (HPP) announced preliminary results of its enhanced Baby Partners program that resulted in more babies born at healthier weights and lower costs associated with deliveries. HPP’s Baby Partners program optimizes the health outcomes of moms and babies through proactive case management, outcomes-based incentives, special support for at-risk pregnancies and Doula services. HPP enhanced the program through a 3-year Health Care Innovation Award sponsored by CMS in partnership with Finity, Inc.
  • CMS provides ICD-10 update On October 29, CMS provided an update about ICD-10 implementation. According to CMS, the total number of claims processed has been consistent before and after the October 1 implementation date. Additionally, the total number of claims rejected has been consistent.

  • Other

    On October 21, Kevin Barrett met with Congressman Tom Price (R-GA) in Washington, DC. During the meeting, Barrett gave an update about the Emdeon acquisition of Altegra Health, informing Dr Price that the acquisition did not impact the recent growth of the office located in Alpharetta. (Dr Price’s district includes the Alpharetta office.)
    Picture (from L to R): Tim Jones, Director, Federal & State Government Relations, Altegra Health; Kevin Barrett; Congressman Tom Price

    From L to R: Tim Jones, Director, Federal & State Government Relations, Altegra Health; Kevin Barrett; Congressman Tom Price


  • Kaiser Family Foundation releases analysis of MA penetration rates On October 20, the Kaiser Family Foundation released an analysis of MA penetration rates and growth rates in counties across the country. A small share (9 percent) of all Medicare beneficiaries lives in an area where at least 50 percent of all beneficiaries are in a MA plan. One-quarter of all Medicare beneficiaries lives in an area with relatively low MA (less than 20 percent).
  • Newly-enrolled in New Jersey Medicaid could lose coverage This story reports that a “significant” number of the New Jersey residents who enrolled in health insurance due to the Medicaid expansion could lose their coverage if they fail to file renewals, according to Valerie Harr, Director of the state’s Division of Medical Assistance and Health Services. The state sends a renewal application 75 days before the annual redetermination deadline, with follow-up notices sent 60 days and 30 days prior to the deadline. If the state is not able to determine whether the person is still eligible, it sends a termination letter 20 days before the deadline.
  • Michigan and Illinois announce cloud-based technology for Medicaid On October 21, the Michigan Department of Health and Human Services announced that it has worked with the State of Illinois; the Michigan Department of Technology, Management and Budget; and CNSI to launch the second phase of the nation’s first completely automated real-time and cloud-enabled system. Michigan residents will benefit from improved health care delivery and reduced costs through the Medicaid Management Information System technology.
  • ACAP releases a report of Medicaid MCO savings On October 22, ACAP released a new report that examined projected savings of capitation in the Medicaid program. The report, authored by the Menges Group, pegged overall savings to Medicaid programs owing to capitation at $2.1 billion in 2011, and projected that these savings would increase to $6.4 billion in calendar year 2016. Much of these savings could be attributed to an increasing prevalence of contracting with Medicaid MCOs among states in the intervening years, as well as an overall increase in the number of lives covered by Medicaid owing to its expansion under the provisions of the ACA.
  • GAO releases report about CMS oversight of Medicaid enrollment On October 23, the GAO released a report identifying gaps in the CMS oversight of Medicaid enrollment and coordination with the exchanges resulting from the ACA expansion. GAO found that CMS has excluded from review federal Medicaid eligibility determinations in the states that have delegated authority to the federal government to make Medicaid eligibility determinations through the federal exchange. GAO also found that CMS reviews of states’ expenditures do not use information obtained from the reviews of state eligibility determination errors to better target its review of Medicaid expenditures for the different eligibility groups.
  • CMS releases August 2015 Medicaid enrollment report On October 26, CMS released the August 2015 Medicaid enrollment report. Over 72.4 million were enrolled in Medicaid and CHIP in August 2015. The report included state-by-state enrollment statistics.
  • ACAP sends letter to MedPAC regarding home health assessments On October 29, ACAP sent a letter to MedPAC raising concerns about its proposal to eliminate MA risk scores submitted through home health assessments. Specifically, ACAP raised it concerns that the policy would decrease the accuracy of risk adjustment payments for integrated D-SNPs that enroll full-benefit dual-eligible beneficiaries.
  • Congress passes legislation funding the federal government On October 30, the Senate approved a bill passed by the House earlier in the week that would raise the federal debt limit and set the maximum amount to fund the government for 2016 and 2017. Of note, the legislation prevents an expected 50 percent increase in Part B premiums (approximately $160 monthly) for certain Medicare populations, including the dual eligibles. President Obama is expected to sign the bill into law.
  • Alliance for Health Reform released information on housing and health In October, the Alliance for Health Reform released resources on the relationship between housing and health. The packet notes that evidence is growing that housing, a social determinant of health, is an important factor in the health status of various populations.
  • Health Affairs releases study of switching between MA and FFS In October, Health Affairs released a study finding that high-cost patients had substantial rates of leaving MA plans and joining Medicare FFS. The study found that the switching rate from 2010 to 2011 away from MA and to FFS exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing homes care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among dual eligibles.
  • GAO releases report about improper payments On October1, the GAO released a study finding that the proper federal government payment estimate, attributable to 124 programs across 22 agencies in FY 2014, was $124.7 billion, up from $105.8 billion in FY 2013. The almost $19 billion increase was primarily due to the Medicare, Medicaid, and Earned Income Tax Credit programs, which account for over 75 percent of the government-wide improper payment estimate.
  • CMS releases 2016 MA Star Ratings On October 8, CMS released the 2016 MA Star Rating. The website contains plan-by-plan ratings for Star measure.
  • California approves Blue Shield-Care1st merger On October 8, California Department of Managed Health Care Director Shelly Rouillard issued an order approving Blue Shield of California's acquisition of Care1st Health Plan.
  • Kaiser Family Foundation releases analysis of MA access in 2016 On October 13, the Kaiser Family Foundation released an analysis of the availability of MA plans nationwide and by state in 2016, and tracks changes in plan availability since 2012. On average, Medicare beneficiaries will be able to choose among 19 MA plans in 2016, a slight increase from last year (18 plans per beneficiary). The majority of plans available in 2015 will continue to be offered in 2016.
  • NAMD sends letter regarding increasing Part B premiums On October 14, NAMD sent a letter to congressional leaders noting concerns about the upcoming increase in Part B premiums. The letter notes that shifting state resources to accommodate this unprecedented increase through MSP will put undue pressure on state Medicaid programs, as well as other state programs and priorities. The letter contains estimates of the state-by-state budgetary impact.
  • Kaiser Family Foundation releases 50-state Medicaid survey On October 15, the Kaiser Family Foundation released its annual 50-state Medicaid budget survey for state FY 2015-2016. According to the survey, states remain focused on strategies and initiatives to improve the effectiveness and outcomes of care, and to slow the growth in the cost of care, primarily through the increased adoption of MCOs. Emerging priorities mentioned by Medicaid directors include population health and social determinants of health.
  • Kaiser Family Foundation releases report of Medicaid enrollment and spending growth On October 15, the Kaiser Family Foundation released a report of Medicaid enrollment and spending growth with a focus on state FY 2015-2016. Medicaid enrollment and spending increased substantially in FY 2015, the first full year of implementation of the major ACA coverage expansions. Total Medicaid enrollment and spending growth is projected to slow in FY 2016; looking ahead, states will monitor the effects of the ACA and other payment and delivery system reforms on spending.
  • Social Security benefits will not rise in 2016 On October 15, the Social Security Administration announced that monthly Social Security and Supplemental Security Income (SSI) benefits for nearly 65 million Americans will not automatically increase in 2016. Should there be an increase in the Medicare Part B premium, beneficiaries who have their Medicare Part B premiums paid by state medical assistance programs will see no change in their Social Security benefit; the state will be required to pay any Medicare Part B premium increase.
  • CMS releases Medicaid MCO data On October 16, CMS released 2013 Medicaid MCO enrollment data. The nationwide data is broken down by program and population, as well as by individual state; and provides a snapshot of managed care enrollment as of July 1st, 2013.


  • House Judiciary Committee holds another hearing about health insurer mergers On September 29, the House Judiciary Committee held another hearing about the Aetna/Humana and Anthem/Cigna mergers. While Congress has no role in the decision of whether to allow the mergers to go forward, some have expressed skepticism about the effect on competition. Members of Congress have been subjected to heavy lobbying from the American Medical Association and the American Hospital Association, who oppose the proposed mergers.
  • CMS releases ACA risk reports On October 1, CMS released a status report about the ACA risk adjustment, re-insurance, and risk corridor programs. For 2014, the risk adjustment program will transfer approximately $4.6 billion among health plans. The re-insurance program will be paying $7.9 billion in re-insurance claims for 2014.
  • Kaiser Family Foundation releases analysis of 2016 insurance exchange premium increases On October 1, the Kaiser Family Foundation released an analysis of premium changes in the 2016 insurance exchanges. Examining major cities in 13 states and the District of Columbia, the analysis found a 4.4 percent average increase in premiums.

  • HHS OIG releases report about New York insurance exchange On September 21, the HHS OIG released a report finding that not all of the New York state insurance exchange's internal controls were effective in ensuring that individuals were enrolled in plans according to federal requirements. The internal controls were not always effective for verifying annual household income, resolving inconsistencies in eligibility data, and verifying eligibility for minimum essential coverage through employer-sponsored insurance (ESI) and ensuring that insurance affordability programs were authorized only for individuals who do not have ESI.
  • HHS releases revised coverage estimates On September 22, HHS Secretary Burwell discussed the upcoming open enrollment for the insurance exchanges. Using updated data, HHS now estimates that 17.6 million uninsured people have gained coverage; coverage gains refer to different sources of coverage, including Medicaid, the insurance exchanges, and individual market coverage. Approximately 10.5 million uninsured Americans are eligible for exchange coverage in the upcoming open enrollment.
  • Senate Judiciary Committee holds hearing on proposed mergers On September 22, the Senate Judiciary Committee held a hearing examining the proposed Aetna-Humana and Anthem-Cigna deals. Critics of the deal included the head of the American Hospital Association. Though many senators questioned the deal, the deal is not believed to face congressional opposition.

  • Georgia insurance premiums to rise in 2016 This story reports that Georgia individual or family health insurance premiums will experience double-digit increases in 2016.
  • HHS OIG finds contracting flaws in federal insurance exchange On September 14, the HHS OIG released a report finding that contracting officers and contracting officer's representatives for the federal insurance exchange did not always manage and oversee contractor performance as required by federal requirements and contract terms. Because CMS did not always provide adequate contract management and oversight for the federal exchange contracts, (1) contractor delays and performance issues were not always identified, (2) a contractor incurred unauthorized costs that increased the cost of the contract, (3) contracting officers in all government agencies did not have access to contractor past-performance evaluations when making contract awards, and (4) critical deliverables and management decisions were not properly documented.
  • Census Bureau releases data about improved uninsured rate On September 16, the US Census Bureau released a report finding that the percentage of people without health insurance coverage for the entire 2014 calendar year was 10.4 percent, down from 13.3 percent in 2013. The number of people without health insurance declined to 33.0 million from 41.8 million over the period.
  • GAO releases report about state implementation of insurance exchanges On September 16, the GAO released a report finding that states reported that they spent approximately $1.45 billion of the federal insurance exchange grant funding on IT projects supporting the exchanges, as of March 2015. The study also found that CMS did not always clearly document, define, or communicate its oversight roles and responsibilities to states as called for by best practices for project management. The report also found that states reported a number of challenges in establishing the systems supporting their exchanges, including project management and oversight, system design and development, resource allocation and distribution, and marketplace implementation and operation.

  • CMS releases insurance exchange enrollment statistics On September 8, CMS provided enrollment statistics for the insurance exchanges as of June 30. At this time, approximately 9.9 million were covered by the exchange. Approximately 7.2 million were enrolled on the federal exchange and 2.7 million were enrolled on the state exchanges. The data includes state-by-state enrollment figures.
  • AMA releases study on impact of health insurer mergers On September 8, the AMA released a study regarding the impact of the recent health insurer mergers. According to the study, the mergers would exceed federal antitrust guidelines designed to preserve competition in as many as 97 metropolitan areas within 17 states. The two mergers would also diminish competition in up to 154 metropolitan areas within 23 states.
  • GAO releases analysis of insurance exchange plans in 2014-15 On September 9, the GAO released a study entitled, “The Range of Premiums and Plan Availability for Individuals in 2014 and 2015.” According to the study, individual market consumers generally had access to more health plans in 2015 compared to 2014, and in both years the lowest-cost plans were available through exchanges in most of the 1,886 counties GAO analyzed in the 28 states for which it had sufficiently reliable data for plans offered either on or off an exchange. In addition, in the 28 states included in GAO’s analysis, from 2014 to 2015 the minimum premiums for silver plans available to a 30-year-old increased in 18 states, decreased in 9 states, and remained unchanged in 1 state.
  • House committee holds hearing on health insurer mergers On September 10, the House Judiciary Committee held a hearing about the proposed health insurer mergers. AHIP testified in support of the mergers, while the AMA and AHA offered criticism of the mergers. House members expressed keen interest in the mergers, but their views did not appear to have crystallized into support or opposition.

  • Technology

  • Commonwealth Fund examines senior technology tool This story contains a profile of a community-based social support program, linkAges, that is designed to help older adults continue to live independently and remain engaged in their communities. By leveraging technology and social interactions across generations, the program aims to combat loneliness and isolation and mitigate their adverse health effects. The program’s four related components include a community-based network that allows members to exchange needed services; a collection of senior-friendly services and resources informed by community-generated reviews; information about seniors’ day-to-day lives, interests, needs, and goals that they would like their doctors to know about; and passive in-home monitoring of utility usage to detect changes in seniors’ physical and social health status.
  • GAO reports about CMS readiness for ICD-10 On September 17, the GAO released a report documenting all CMS efforts to implement ICD-10.


  • CMS releases July 2015 Medicaid enrollment report On September 28, CMS released the July 2015 Medicaid enrollment report. Over 72 million were enrolled in Medicaid and CHIP in July 2015. The report included state-by-state enrollment statistics.
  • Coalition sends letter about Part B premium increases On September 30, the Medicare Rights Center sent a letter to congressional leaders as part of a coalition raising concerns about the rise of Part B premiums. The letter notes that there may be insufficient allocations for the Qualified Individuals (QI) program to cover the unanticipated premium increases. The letter was signed by AHIP and the Blue Cross Blue Shield Association, among others.
  • Senate introduces legislation to prevent MA plan termination On September 30, Senators Bob Casey (D-PA) and Rob Portman (R-OH) introduced legislation that would prevent the termination of MA plans that serve low-income members and provide funds for plans with a high percentage of dually-eligible and low-income members and provide funds for a plans with a high percentage of dually-eligible and low-income beneficiaries to develop targeted interventions to help those beneficiaries.

  • CMS announces MA projected enrollment On September 21, CMS announced the average MA premium will decrease by $0.31 in 2016, from $32.91 on average in 2015 to $32.60 in 2016. Access to the MA program will remain strong, with 99 percent of beneficiaries having access to a plan. MA enrollment is projected to increase to approximately 17.4 million enrollees, which represents approximately 32 percent of the Medicare population.
  • CMS releases 2016 Medicaid MCO rate setting guide On September 23, CMS released its 2016 Medicaid MCO rate setting guide. The guide outlines the disclosure requirements of the risk adjustment methodology in rate setting. In addition, rates can take into account expenditures on care coordination.
  • North Carolina enacts Medicaid reform legislation On September 23, North Carolina enacted legislation reforming the Medicaid program from FFS to one that injects competition between provider-led health plans and commercial insurers and rewards healthier outcomes for Medicaid patients.

  • Avalere Health releases report about MA market competition On September 9, Avalere Health released a report finding that 28 MA plans who entered the market between 2012 and 2015 currently offer plans to beneficiaries. Together, these new players offer 104 plan options, which are available to 13.6 million beneficiaries in 24 states. Of the 28 plans referenced above, 15 – or 54 percent – are provider-sponsored.
  • Michigan Medicaid to be led by Chris Priest On September 10, Michigan Department of Health and Human Services Director Nick Lyon nominated Chris Priest to lead its Medicaid program, effective October 12. Priest most recently served as Governor Rick Snyder’s Deputy Director of Strategy, where he advised the governor on various issues, including health care and insurance. Previously, he served as the Director of the Bureau of Medicaid Policy and Health System Innovation in the former Michigan Department of Community Health, and as Project Manager involved with the insurance exchange in the Michigan Department of Licensing and Regulatory Affairs.
  • Kaiser Family Foundation examines Medicare ACO savings This story reports on the Kaiser Family Foundation’s study of ACO savings. Last year, 196 ACOs saved Medicare money, while 157 ACOs cost more than expected. Medicare ultimately did not realize any savings because it paid out bonuses to 97 ACOs, but only three of the costly ACOs had to repay Medicare for losses their patients incurred.
  • JAMA releases study of patient re-admission characteristics On September 14, the Journal of the AMA’s Internal Medicine released a study finding that patient characteristics not included in Medicare’s current risk adjustment methods explained much of the difference in re-admission risk between patients admitted to hospitals with higher vs lower re-admission rates. Hospitals with high re-admission rates may be penalized to a large extent based upon the patients they serve. Characteristics include those socio-economic factors which could negatively affect patient health outcomes.

  • ACAP sends letter recommending risk adjustment changes for dual eligibles On September 1, ACAP sent a letter to CMS in collaboration with other organizations raising concerns about how D-SNPs and MMPs are reimbursed. The letter requests that the risk adjustment system be improved for the 2016 MMP plan year and for the 2017 D-SNP plan year. Improvements would include revising or adding demographic or condition categories so that the risk adjustment system truly predicts the costs of dual eligible beneficiaries’ care, and the care of all Medicare beneficiaries whom are chronically ill, disabled, or have a behavioral health condition.
  • CMS releases plan to address Medicare health equity On September 8, CMS released its first-ever plan to address health equity in Medicare. The priorities and activities described in the plan were developed during a year-long process in collaboration with NORC at the University of Chicago. Six priority areas were identified, including expanding the collection, reporting, and analysis of standardized data; evaluating disparities impacts and integrating equity solutions across CMS programs; and developing and disseminating promising approaches to reduce health disparities, among other priorities.
  • Kaiser Family Foundation releases updated analysis of dual eligible demonstrations On September 8, the Kaiser Family Foundation released an update of its state-by-state analysis of the dual eligible demonstrations. This update reflects the recent MOU signed in Rhode Island, as well as recent enrollment statistics in the demonstrations.

  • Other

  • NCQA announces new health plan rating system On September 17, NCQA announced it created a new ratings system for health plan performance in key quality areas. Using a methodology that makes its debut after two years of development, NCQA’s Health Insurance Plan Ratings 2015–2016 compare the quality and services of more than 1,000 health plans that collectively cover 138 million people—over 43 percent of the US population. NCQA studied 1,358 health plans and rated 1,016: 491 private (commercial), 376 Medicare and 149 Medicaid.
  • CMS releases updated ICD-10 questions On September 22, CMS released updated questions and answers regarding ICD-10 implementation. The update includes clarifying that CMS guidance does not change coding guidelines for MA plans.


  • Massachusetts approves 6.3 percent insurance exchange plan rate increase In August, the Massachusetts Division of Insurance approved a 6.3 percent average increase in 2016 for its insurance exchange plans.
  • Florida approves 9.5 percent insurance exchange plan rate increase On August 26, the Florida Office of Insurance Regulation approved a 9.5 percent average increase in 2016 for its insurance exchange plans.
  • Washington approves 4.2 percent insurance exchange plan rate increase On August 27, the Washington Insurance Commissioner approved a 4.2 percent average increase in 2016 for its insurance exchange plans. Washington will have 136 plan options from 12 health plans in 2016.

  • UCLA releases California enrollment statistics On August 18, the UCLA Center for Health Policy Research data finding that the number of California residents ages 19-64 without health insurance declined by 15.5 percent - more than 655,000 resident people - from 2013 to 2014. The Center also released a factsheet estimating that California Medicaid enrollment among the same age group rose from 12.9 percent in 2013 to 19.2 in 2014.

  • Gallup releases uninsured rate survey On August 10, Gallup released state-level data based upon daily surveys conducted from January through June 2015 and includes sample sizes that range from 232 randomly selected adult residents in Hawaii to more than 8,600 in California. Through the first half of 2015, there are now seven states with uninsured rates that are at or below 5 percent: Rhode Island, Massachusetts, Vermont, Minnesota, Iowa, Connecticut and Hawaii. No state, in turn, has reported a statistically significant increase in the percentage of uninsured thus far in 2015 compared with 2013. Nationwide, the uninsured rate fell from 17.3 percent in full-year 2013 to 11.7 percent in the first half of 2015.
  • Booz Allen awarded CMS contract for insurance exchange On August 10, Booz Allen Hamilton announced it had been awarded a contract by CMS to become the system integrator for the federal insurance exchange. Specifically, Booz Allen will lead governance and technical coordination for a complex, interoperable set of systems, while ensuring compliance and alignment with continuing congressional mandates and frequently evolving regulatory requirements. The contract was awarded for $202 million, and is composed of a base plus 4 option years, with the potential for support to continue through July 2020.
  • CDC releases its insurance exchange survey On August 12, the CDC released its National Health Interview Survey from January–March 2015. Among those under age 65, the percentage with private coverage through the insurance exchanges increased from 2.5 percent (6.7 million) in the last 3 months of 2014 to 3.6 percent (9.7 million) in the first 3 months of 2015. Among adults aged 18–64, the percentage uninsured decreased from 16.3 percent in 2014 to 13.0 percent in the first 3 months of 2015.
  • CMS reports insurance exchange special enrollment statistics On August 13, CMS announced that nearly 950,000 new consumers selected a plan through the federal insurance exchange during a special enrollment period between February 23 and June 30, 2015. The report contains state-by-state enrollment statistics.

  • New York reports insurance exchange open enrollment statistics On July 29, New York released its insurance exchange enrollment statistics through February 2015. Over 415,000 were enrolled in an exchange plan, while more than 1.5 million were eligible and enrolled in Medicaid. More than 89 percent of enrollees reported being uninsured at the time of application.
  • California reports insurance exchange open enrollment statistics In July, California released its insurance exchange enrollment statistics through December 2014. From October – December 2014, total enrollment in Medicaid grew by over 270,000. Approximately 340,000 residents applied and were determined eligible for enrollment in the exchange.
  • Blue Cross and Blue Shield of North Carolina increases insurance exchange rate request On August 6, Blue Cross and Blue Shield of North Carolina reported that it would be seeking a 34.6 percent increase in its 2016 insurance exchange rates. The increase is due to data showing that enrollees are unhealthy and use more health care services than expected.


  • Manatt identifies future Medicaid issues On August 11, Manatt experts Cindy Mann and Deb Bacharach provided insights about the top future Medicaid issues. Among other issues, the column addresses Medicaid as a value-based purchaser which can hold health systems—often acting in partnership with social services and community-based supports—accountable not only to cure the sick but to help people in the communities stay or become healthy. The column recommends that the Medicaid IT infrastructure enabling the gains in coverage and improvements in consumer experience achieved to date needs to be completed in some states and at the federal level, and kept current with new technologies and efficiencies.
  • Commonwealth Fund publishes study about MA competition On August 25, the Commonwealth Fund published a study titled, “Competition among Medicare’s Private Health Plans: Does It Really Exist?” According to the study, 97 percent of markets in US counties are highly concentrated and therefore lacking in significant MA plan competition. Among the 100 counties with the greatest numbers of Medicare beneficiaries, 81 percent do not have competitive MA markets.
  • CMS releases Medicare ACO results On August 25, CMS issued 2014 quality and financial performance results for Medicare ACOs. According to the results, the 20 ACOs in the Pioneer ACO Model and 333 Medicare Shared Shavings Program ACOs generated more than $411 million in total savings in 2014, which include all ACOs’ savings and losses. At the same time, 97 ACOs qualified for shared savings payments of more than $422 million by meeting quality standards and their savings threshold.
  • CBO releases updated budget forecast On August 25, the Congressional Budget Office released a report, “An Update to the Budget and Economic Outlook: 2015 to 2025.” According to the report, federal mandatory outlays will be $199 billion higher in 2015 than they were last year. Federal spending for the major health care programs accounts for approximately 50 percent of that increase: Outlays for Medicare (net of premiums and other offsetting receipts), Medicaid, CHIP, and subsidies for health plans purchased through insurance exchanges and related spending are expected to be
$110 billion (12 percent) higher this year than they were in 2014.
  • Minnesota Medicaid application backlog to be corrected This story reports that approximately 28,000 Minnesota households will lose their Medicaid coverage at the end of the month due to the state’s backlog of applications. This population has either become ineligible for Medicaid or is still eligible but did not submit necessary information in time. This should have been established in January; however, a series of computer glitches delayed the loss of coverage for this population, in addition to a delay in renewals for an estimated 127,000 households.

  • Kaiser Family Foundation releases Medicaid MCO enrollment statistics On August 17, the Kaiser Family Foundation released its Medicaid managed care market tracker. The tracker includes Medicaid MCO enrollment by state and plan.
  • Pennsylvania ACA Medicaid expansion wait times reduced This story reports that Pennsylvania's ACA Medicaid expansion this year by Governor Tom Wolf has resulted in shorter time waits to enroll through more streamlined applications. Currently, approximately 2 percent of applicants wait longer than 30 days for a coverage decision, which is reduced from roughly 13 percent previously. Most applications are processed within 22 days.

  • NAMD releases letter to CMS about Medicaid MCO regulations On July 27, the National Association of Medicaid Directors released its letter to CMS concerning the proposed Medicaid MCO regulations. Of note, NAMD believes a 3-5 year period is necessary for the implementation of CMS’s quality rating system. NAMD also asks CMS to support states in enhancing their encounter data, rather than removing federal funding while states are working to tackle the complex challenges in this area.
  • ACAP releases letter to CMS about Medicaid MCO regulations On July 27, ACAP released its letter to CMS concerning the proposed Medicaid MCO regulations. Of note, ACAP requests that final regulations clarify that the information used in a state’s risk adjustment methodology be available to MCOs. ACAP also recommends that language be included about care coordination and case management activities, including those directed at addressing social determinants of health, promoting patient engagement and assisting enrollees in improving self-sufficiency, for MLR calculation purposes.
  • MHPA releases letter to CMS about Medicaid MCO regulations On July 27, MHPA released its letter to CMS concerning the proposed Medicaid MCO regulations. Of note, MHPA requests that CMS include language in the final rule that identifies and acknowledges the role and impact of social determinants of health on quality ratings achieved by plans, recognizing that Medicaid beneficiaries represent a high risk requiring appropriate risk adjustment when compared to privately insured beneficiaries. MHPA also recommends that CMS and states adopt uniform encounter reporting standards to simplify encounter reporting and reduce the significant administrative burden that states and Medicaid MCOs incur with the establishment of variable and unique reporting standards.
  • Puerto Rico financial crisis affects MA and Medicaid This story reports about the impact of Puerto Rico’s financial crisis on health care. Because of the island’s finances, the Medicaid program lacks access to credit and is so short on cash that it owes providers $200 million, a figure it has reduced from $350 million; doctors are leaving as a result. The island’s Medicaid program serves nearly 1.6 million people, and nearly 75 percent of the Medicare population is enrolled in MA.
  • CMS releases Medicaid enrollment data from MBES On August 6, CMS released Medicaid enrollment data through March from states as part of their Medicaid expenditure reporting through the Medicaid Budget and Expenditure System (MBES). The enrollment information is a state-reported count of unduplicated individuals enrolled in the state’s Medicaid program at any time during each month in the quarterly reporting period. The enrollment data identifies the total number of Medicaid enrollees, and for states that have expanded Medicaid, provides specific counts for the number of individuals enrolled in the new adult eligibility group, also referred to as the “VIII Group”.

Notable Public Policy and Advocacy Efforts

On July 27

Altegra Health sent a letter to CMS in response to its proposed regulations concerning Medicaid MCOs. Download the Altegra Health Response Letter:
Altegra Health Response Letter


  • AHIP selects Tavenner as next CEO On July 15, AHIP's Board of Directors unanimously elected Marilyn Tavenner as AHIP President and CEO. Tavenner previously served as CMS Administrator. She also has held a number of leadership roles with the Hospital Corporation of America (HCA), where she was President of HCA's Central Atlantic Division as well as Group President of Outpatient Services.
  • CMS releases FAQ about RADV in the insurance exchanges On July 16, CMS released a FAQ document about the risk adjustment data validation program (RADV) for insurance exchange plans. The document states that CMS will not conduct RADV on 2014 data, originally one of two preliminary testing years. CMS will still conduct RADV in 2016 for 2015 benefit year data - thus, issuers and auditors will have one preliminary testing year instead of two in which to implement and test the RADV program, and adjust their audit procedures in response.
  • House Judiciary Committee to hold hearing on health insurer mergers On July 23, the house Judiciary Committee announced it would be holding hearings in September examining the recent health insurer mergers. The focus of the hearing is whether the ACA was a factor in the consolidation of the health insurance industry.

  • CMS provides SHOP update On July 2, CMS provided an update the ACA Small Business Health Option Program (SHOP). According to the update, approximately 85,00 have 2015 coverage through the SHOP through approximately 10,700 small employer as of May 2015. These totals do not include employers that began coverage in 2014 and have not yet renewed their coverage for 2015.
  • CMS releases federal insurance exchange enrollee statistic On July 8, CMS released statistic by county for those enrolled in the federal insurance exchanges.
  • Gallup reports low uninsured rate On July 10, Gallup released a poll finding that the uninsured rate has dropped to its lowest level, 11.4 percent, since it began tracking the statistic in 2008. The figure, which documents the rate between April and June, is the result of survey with 44,00 people. The biggest declines were seen in the African-American and Hispanic communities, and among those making less than $36,000 a year, with all groups reporting declines of nearly 10 percent points.

  • Health IT

  • CMS provides additional ICD-10 guidance On July 27, CMS released additional guidance about the ICD-10 transition. Notably, CMS reiterates that Medicare claims with a date of service on or after October 1 will be rejected if they do not contain a valid ICD-10 code. CMS also reiterates that, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes.

  • CMS announces ICD-10 transition policies On July 6, CMS and the American Medical Association announced efforts to help providers with the ICD-10 transition. As part of this announcement, CMS released a document saying the Medicare review contractors will not deny physicians or other practitioners claims billed under the Part B physicians fee schedule through wither automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family for 12 months following the October 1 transition. A valid ICD-10 code will be required on all claims starting on October 1, 2015. Additionally, for all quality reporting completed for program year 2015 Medicare clinical quality data review contractor will not be subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use (MU) penalty during primary source verifications or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes.
  • White House releases update on Precision Medicine Initiative On July 8, the White House provided an update about its Precision Medicine Initiative (PMI). As part of this update, the White House released a draft statement of principles focusing on how health data can be used while protecting patient privacy.
  • House approves 21st century cures bill On July 10, the US House approved the 21st Century Cures bill by a 344-77 vote. The bill, which has been considered through a significant initiative by the Energy & Commerce Committee over the past year, includes provisions excluding certain health-related technology from FDA regulation.


  • MHPA sends letter on Medicaid MCO proposed regulations On July 27, MHPA sent a letter to CMS in response to its proposed regulations concerning Medicaid MCOs. Of note, MHPA opposed the 85 percent MLR national mandate. MHPA also recommends that CMS and states adopt uniform encounter reporting standards to simplify encounter reporting and reduce the significant administrative burden that states and Medicaid MCOs incur with the establishment of variable and unique reporting standards.
  • CMS releases May 2015 Medicaid enrollment report On July 28, CMS released the May 2015 Medicaid enrollment report. Over 71.6 million were enrolled in Medicaid and CHIP in May 2015, which is more than 509,000 than April 2015. The report includes state-by-state enrollment statistics.
  • CMS releases MA enrollment statistics On July 28, CMS released Medicare enrollment statistics coinciding with the 50th anniversary of the legislation establishing the program. According to the report, over 17 million were enrolled in MA in May 2015. The report contains state-by-state MA enrollment statistics.
  • Senate Finance Committee releases stakeholder comments on Medicare chronic care initiative On July 28, the Senate Finance Committee released stakeholder submissions from its request for comments on improving chronic care for Medicare enrollees. Submissions include AHIP, Anthem, Blue Cross Blue Shield Association, and UnitedHealth Group, among others. Altegra Health also submitted a letter to the Finance Committee.
  • CMS releases 2016 Part D LIS amounts On July 29, CMS reported that that the average premium for a basic Medicare Part D prescription drug plan in 2016 will be approximately $32.50 per month. The report also contains the average state-by-state LIS amounts.
  • Rhode Island signs MOU to begin dual eligible demonstration On July 30, CMS announced that Rhode Island has become the 13th state to enact a dual eligible demonstration. The demonstration is targeted to enroll 30,000 full dual eligibles. Enrollment is scheduled to begin on September 1.
  • CMS provides guidance on annual LIS re-determination process On July 30, CMS released its annual guidance on the annual re-determination process for Medicare Part D LIS deemed status, also known as “redeeming.” If, during the subsequent re- determination process beginning in July 2015, it is determined that an individual continues to be eligible for LIS for the next calendar year, the individual will automatically be redeemed for all of 2016. In September, CMS and the Social Security Administration (SSA) will issue a joint mailing to beneficiaries whose deemed status will not continue into the next calendar year based on their absence from the July or August state Medicare Modernization Act (MMA) files or SSA’s August file.

  • Michigan ACA Medicaid expansion leads to more primary care access In July, Health Affairs released a study finding that primary care appointments availability for new Medicaid enrollees increased after ACA Medicaid expansion in Michigan. During the study period, between March-August 2014, approximately 350,000 Michigan residents enrolled in Medicaid MCOs, and 272,000 enrolled in subsidized private insurance plans. The study found that appointment availability increased 6 percentage points for new Medicaid patients and decreased 2 percent points for new privately-insured patients, compared to availability before the expansion.
  • Kaiser Family Foundation releases study about LIS enrollees On July 17, the Kaiser Family Foundation released a study titled, "To Switch or Be Switched: Examining Changes in Drug Plan Enrollment among Medicare Part D Low-Income Subsidy Enrollees.” In 2015, 11.7 million Part D enrollees (30 percent of all Part D enrollees) were receiving the LIS; of this total, 8.0 million (68 percent) were enrolled in stand-alone prescription drug plans (PDPs) and 3.7 million (32 percent) in Medicare Advantage drug plans (MA-PDs). Overall, LIS enrollees changed PDPs at a higher rate than non-LIS enrollees for the 2010 plan year (19 percent versus 11 percent). However, the 19 percent includes 15 percent who were re-assigned by CMS and 4 percent who voluntarily switched to a new PDP—a significantly lower voluntary switching rate than the 11 percent rate among non-LIS enrollees.
  • MedPAC releases annual databook On July 17, MedPAC released its annual databook concerning Medicare spending and enrollment. According to the report, 16.4 million are enrolled in MA plans in 2015, which is 30 percent of all Medicare beneficiaries; the report includes state-by-state enrollment statistics. The report also notes that MA plan quality measures generally show improvement between 2012 and 2014. The report notes only 5 percent of all Medicare enrollees are partial dual eligibles; 40 percent of SLMBs are enrolled in MA plans and 44 percent of QIs are enrolled in MA plans.
  • Federal agencies allow extension of human services funding On July 20, CMS and other government agencies released guidance regarding the costs associated with building shared state-based information technology systems to be allocated across all benefitting programs. The original timeline allowed human services programs to benefit from investments in the design and development of state eligibility-determination systems for the state insurance exchanges, Medicaid, and CHIP through December 31, 2015; this has been extended to December 31, 2018. The exception reflected the focus on streamlining enrollment in health and human services programs while leveraging funding efficiencies at the state level.
  • NASHP issues brief on ACA eligibility and enrollment On July 21, the National Academy on State Health Policy released a brief, “State Enrollment Experience: Implementing Health Coverage Eligibility and Enrollment Systems under the ACA.” Drawing on key informant interviews and ongoing engagement with states from 2013-2015, this brief examines states’ early experiences implementing ACA’s eligibility and enrollment requirements; highlights promising practices and lessons learned; provides some context on the state experience; and concludes with possible areas of focus for future enrollment and implementation efforts. The brief notes that state Medicaid directors and CMS are still working on a number of system and policy improvements to increase efficiency and improve communication between federal and state agencies, including stabilizing system timelines and testing, eliminating redundancies between state and federal systems, improving formats, for shared information upgrading notices and communication about coverage, and aligning eligibility policies.
  • Annual Medicare Trust Fund report released On July 22, CMS released the annual Medicare Trust Fund report. According to the report, the share of Medicare enrollees in private health plans is projected to increase from 30.2 percent in 2014 to 34.8 percent in 2024. Modest increases are expected in private plan penetration rates between 2018 and 2024 due to higher relative bonus payments stemming from assumed improvements in quality rating scores. The report warns that the estimated monthly Part B premium for 2016 could be $159.30.
  • MACPAC comments on Medicaid MCO regulations On July 22, MACPAC sent a letter to CMS in response to the Medicaid MCO proposed regulations. MACPAC strongly endorses CMS’ efforts to improve transparency and the availability of data that MACPAC and others use to evaluate the performance of Medicaid MCOs. MACPAC also urges CMS to consider which of the new administrative burdens that would be imposed on states are necessary for improvement of access and quality as well as for responsible stewardship of public resources.

  • CMS releases 2016 final Medicare marketing guidelines On July2, CMS released the 2016 final Medicare marketing guidelines. Changes from the 2015 guidelines include that Star ratings information documents must be distributed when the summary of benefits and/or the enrollment form is provided to beneficiaries. In addition, MA plans may provide marketing materials describing other health-related lines of business when marketing covered plans to prospective enrollees, provided that such materials are in compliance with applicable state law and federal Medicare regulations.
  • HHS OIG releases report about Medicaid MCO encounter data On July 3, the HHS OIG released a report finding that, although states' reporting of Medicaid MCO encounter data to the Medicaid Statistical Information System (MSIS) improved since 2009, 11 states are still not reporting data for all contracted MCOs and 8 states are not reporting at all. The HHS OIG examined the third quarter FY 2011 MSIS claims files for the 38 states that had the types of MCO programs for which encounter data must be reported to MSIS.
  • Commonwealth Fund recommends options for low-income Medicare beneficiaries On July 8, the Commonwealth Fund released recommendations about modernizing Medicare's benefit design and low-income subsidies. Notably, the grief recommends the adoption of "Medicare Essential," which would modernize Medicare's benefit design by offering a new option for a supplemental premium sponsored by Medicare with integrated benefits, including prescription drugs. The second recommendation would protect low=income beneficiaries up by expanding premium subsidies and reducing cost-sharing for beneficiaries up to 200 percent of poverty with the expanded assistance provided directly by Medicare.
  • Slavitt nominated to be CMS Administrator On July 9, President Obama formally nominated Andy Slavitt, who currently serves as CMS Acting Administrator. Slavitt first joined CMS to help with the federal insurance exchange website. The Blue Cross Blue Shield Association supported the nomination.
  • MA Audits of 4 plans released This story reports that MA audits of four plans have been made public: an Aetna plan in New Jersey, Independence Blue Cross in the Philadelphia area; Lovelace Health Plan in Albuquerque, NM, and a Care Plus plan in South Florida. Auditors concluded that risk scores were too high for more than 800 of the 1,005 patients, which in many cases, but not all, led to overpayments.

Notable Public Policy and Advocacy Efforts

. . . On June 11

Altegra Health sent a letter to CMS in response to a proposed rule that will extend access to enhanced federal financial participation for Medicaid eligibility and enrollment systems past the current regulatory deadline of December 31, 2015. The letter contains recommendations for state eligibility systems that will streamline the Medicare Savings Program application process so that eligible Medicare beneficiaries can receive these benefits in the most efficient manner. Download the Altegra Health Response Letter:
Altegra Health Response Letter

. . . On June 22

On June 22, in response to the Senate Finance Committee’s request for stakeholder comments, Altegra Health sent a letter regarding its experience addressing chronic conditions in Medicare Advantage beneficiaries. Download the Altegra Health Letter:
Altegra Health Letter


  • CMS releases report of ACA reinsurance and risk adjustment payments On June 30, CMS releases a report of the payments to insurance exchange plans through the ACA reinsurance and risk adjustment programs. According to the report, 99.7 percent of plans who set up EDGE servers submitted the data necessary to calculate reinsurance payments and risk adjustments transfers. The report contains all the payments for each plan by state.
  • Washington lobbyists aim to make minor changes to ACA This article details the next ACA issue that could be addressed by Congress following the Supreme Court ruling about the federal insurance exchange subsidies. These include the repeal of the "Cadillac" tax on plans, repeal of the medical device tax, changes to the 30-hour workweek rule, and a repeal of the Independent Payment Advisory Board (IPAB).

  • CDC releases survey of insurance coverage On June 15, the CDC released the document, “Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2014.” The document reports that 36 million were uninsured at the time of interview, 51.6 million had been uninsured for at least part of the year prior to interview, and 26.3 million had been uninsured for more than a year at the time of interview. Among persons under age 65, 170.4 million were covered, including 5.9 million in the insurance exchanges.
  • California insurance exchange examining enrollee health On June 21, the LA Times reported that the California insurance exchange signed a contract with Truven Health Analytics to collect plan data on prescriptions, doctor visits and hospital stays for every enrollee. The effort has raised questions about patient privacy and whether the state is doing enough to inform consumers about how their data will be used. The exchange believes this massive data-mining project is essential to measure the quality of care that patients receive.
  • Supreme Court legalizes federal insurance exchange subsidies On June 25, the US Supreme Court ruled in favor of the constitutionality of subsidies offered through the ACA to those purchasing health insurance through the insurance exchange established by the federal government. The plaintiffs in the case argued that the ACA only offers subsidies to insurance enrollees who live in states that have established their own exchange. In a 6-3 decision, the Supreme Court ruled that the intent of the ACA was to offer subsidies to exchange enrollees regardless of whether they live in a state with its own exchange or one run by CMS.
  • Challenges remain for insurance exchanges following Supreme Court decision This article details the future challenges of the insurance exchanges and their enrollees following the Supreme Court decision to legalized the federal exchange subsidies. The article notes that enrollment is still lower than expected, due in part because the affordability of coverage remains a challenge for low-income families. Additionally, there is uncertainty about the continued operation of the exchanges once the operational funding from the federal government disappears. Exchange plans are also preparing to share quality rating measures in 2017.

  • States receive approval to pursue state insurance exchanges This story reports that Arkansas,Deleware, and Pennsylvania have received conditional approval to pursue a state insurance exchange from HHS.
  • HHS OIG finds that CMS did not ensure accurate payments to insurance exchange plans On June 16, the HHS OIG released a report finding the CMS's internal controls did not effectively ensure the accuracy of nearly $2.8 billion in aggregate financial assistance payments made to insurance exchange plans under the ACA during the first 4 months that these payments were made. Specifically, the OIG found that CMS's reliance in issuer attestation did not ensure that advance cost-sharing reduction (CRS) payment rates identified as outliers were appropriate, CMS did not have systems in place to ensure that financial assistance payments were made on behalf of confirmed enrollees and in the correct amounts, CMS did not have systems in place for state exchanges to submit enrollee eligibility data for financial assistance payments, and CMS did not always follow its guidance for calculating advance CSR payments and does not plan to preform a timely reconciliation of these payments.
  • HHS raises reinsurance payments for insurance exchange plans On June 17, HHS announced that the national co-insurance rate for the 2014 benefit year for the transitional reinsurance program will be increased from 80 percent to 100 percent for non-grandfathered reinsurance-eligible insurance exchange plans' covered claims cost between the attachment point of $45,000 and the reinsurance cap of $250,000. HHS will remit payments to exchange plans starting in August 2015.

  • Q&A about legality of insurance exchange subsidies This article provides background information about the key issues in the Supreme Court case which is examining the constitutionality of ACA federal insurance exchange subsidies.
  • Senator Cassidy introduces legislation addressing federal insurance exchange subsidies On June 9, Senator Bill Cassidy (R-LA) introduced legislation addressing next steps should the ACA federal insurance exchange subsidies be deemed unconstitutional. Of note, the bill would allow state exchanges to use risk adjustment “based on the health status score of each individual enrolled in health insurance coverage in the individual market and not solely based on the aggregate risk of the risk pool with respect to each plan of health insurance coverage.
  • Avalere Health examine insurance exchange silver plan rate filings On June 11, Avalere Health released a study finding that premiums for insurance exchange silver plans will increase 5.8 percent on average across the states analyzed, ranging from a 12.0 percent average increase in Oregon to a 5.3 percent decrease in Michigan. More than two-thirds (68 percent) of 2015 exchange enrollees picked silver plans.

  • Kaiser Family Foundation releases insurance exchange plan financial performance On June 1, the Kaiser Family Foundation examined recently-filed data submitted to state insurance commissioners regarding the 2014 financial performance for insurers in the individual market. Kaiser estimates that the MLR in 2014 for the individual market – including coverage purchased since January 1, 2014 under new ACA rules as well as plans bought prior to then under pre-ACA insurance rules – will range from 81-87 percent, suggesting that actual experience in the first year of changes to the individual insurance market under the ACA may validate the need for somewhat higher premiums. It should be noted that financial results depend heavily on how much insurers will receive in re-insurance payments under the ACA, which will not be known until June 30, 2015.
  • CMS releases 2016 insurance exchange proposed rates On June 1, CMS publicly posted proposed rate increases of 10 percent or more for insurance exchange plans in 2016.
  • CMS releases insurance exchange enrollment in March On June 2, CMS released insurance exchange enrollment as of March 31, 2015. Approximately 10.2 million had “effectuated” coverage, meaning those individuals paid for exchange coverage and still have an active policy in the applicable month. These numbers are consistent with HHS’s effectuated target for the end of 2015.
  • Pennsylvania applies to become state-based insurance exchange On June 2, Pennsylvania Governor Tom Wolf submitted an application to CMS to create a state-based insurance exchange.
  • HHS provides update on stakeholders in Health Care Payment Learning and Action Network On June 3, HHS gave an update about the Health Care Payment Learning and Action Network, which is focused to increase the adoption of value-based payments and alternative payment models. Of note, the Network’s Guiding Committee was appointed, which consists of stakeholders across the health care industry, including health plans such as Anthem, HealthPartners, and Humana, among others.


  • GAO examines Medicaid MCO encounter data On June 29, the GAO released a report examining the service utilization of Medicaid MCO beneficiaries. Examining 2010 encounter data reported by 19 states, GAO the number of professional services utilized per adult beneficiaries ranged from approximately 13 to 55. Professional services included four categories of services: (1) evaluation and management (E/M) services, such as office visits, and emergency room and critical care services; (2) procedural services, such as surgery and opthalmology; (3) ancillary services, such as pathology and lab services; and (4) other professional services, such as oxygen therapy. Utilization varied by state and by length of enrollment.
  • Kaiser Family Foundation releases MA enrollment analysis On June 30, the Kaiser Family Foundation released a report examining MA enrollment as of March 2015. Approximately 16.8 million were enrolled in MA, which is approximately 31 percent of all of all Medicare enrollees and more than 1 million more than in 2014. UnitedHealthcare and Humana account for 39 percent of all MA enrollment and three other plans and BCBS affiliates account for another 33 percent of enrollment in 2015. The report contains state-level enrollemtn statistics, as well as enrollment by number of quality stars.

  • Pennsylvania considering Medicaid MCO expanded access changes for long-term care enrollees Pennsylvania Governor Tom Wolf announced a new Medicaid MCO initiative for long-term care. The plan would involve assigning newly-contracted care managers to oversee government-funded medical and social support services for more than 400,000 Medicaid-eligible seniors and young adults with disabilities. Wolf’s staff began discussing the concept with interest groups earlier in June and began holding public hearings around the state.
  • Kaiser Family Foundation releases map of delivery system reforms This week, the Kaiser Family Foundation released an interactive map of states that have implemented delivery system reform, including ACOs and Medicaid MCO reform.
  • Avalere Health finds less Medicare cancer quality measures On June 22, Avalere Health released an analysis finding that many medical conditions are not fully represented in Medicare quality programs. While conditions such as diabetes and chronic renal disease have 21 measures each, prostate cancer and lung cancer each have only three measures. Among cancers in the top 20 highest impact conditions, there are currently no Medicare quality measures for endometrial cancer.
  • CMS releases April 2015 Medicaid statistics On June 23, CMS released its Medicaid enrollment statistics through April 2015. Over 71.1 million were enrolled in Medicaid and CHIP in April 2015, more than 76,000 than in March 2015. An additional 12.3 million were enrolled in Medicaid and CHIP as of April 2015 than in October 2013.
  • CMS announces creation of ACO Investment Model On June 25, CMS announced the creation of the ACO Investment Model. The ACO Investment Model is an initiative developed by the Center for Medicare & Medicaid Innovation for organizations participating as ACOs in the Medicare Shared Savings Program. The ACO Investment Model is a new model of pre-paid shared savings that builds on experience with the Advance Payment Model to encourage new ACOs to form in rural and underserved areas and current Medicare Shared Savings Program ACOs to transition to arrangements with greater financial risk.

  • MACPAC releases annualJune report On June 15, MACPAC submitted its annual June report to Congress. The report profiles Medicaid supplemental payments in delivery system reform; coverage of Medicaid adult benefits; the intersection of Medicaid and child welfare; behavior health in Medicaid; and psychotropic medication use among Medicaid beneficiaries.
  • MedPac releases annual June report On June 15, MedPac submitted its annual June report to Congress. Different approches to MA coding intensity adjustment are discussed, including an across-the-board adjustment to all plans; plan-specific adjustments; more stringent coding rules, including the use of encounter data; adjustments to plans based upon geography; and quality-based adjustments. The report also discusses the increasing number of Medicare and MA beneficiaries from the baby boomer generation.
  • Massachusetts releases audit of Medicaid MCOs On June 16, the Massachusetts state auditor released an audit of its Medicaid MCO program. The report found that the state Medicaid program unnecessarily spent $233 million by paying medical providers directly when the medical services should have been paid for by its affiliated MCOs. The audit also found that the agency could have additionally saved up to $288 million if its MCO contracts had been more specific as to whether certain services should have been covered.
  • CMS RADV audit disclosed This article reports that PacifiCare, a MA subsidiary of UnitedHealth Group in Washington State, was found to overbill Medicare through a RADV. Medicare paid the wrong amount for 128 of the 201 patients, an error rate of nearly 66 percent. Payments were too high for 98 of the patients, too low for 30 of them; in total, the plan was overpaid by $381,776 during 2007. Auditors cited a "lack of sufficient documentation of a diagnosis" most often as the cause for either denying or slashing payments.

  • MACPAC supports increased Medicaid funding for eligibility improvements On June 1, MACPAC sent a letter commenting on a proposed rule to extend federal funding of state Medicaid eligibility system upgrades. MACPAC supported this rule because it improves the eligibility process, enhances data collection and reporting, and improves state Medicaid administrative capacity.

  • CMS releases March 2015 Medicaid enrollment statistics On June 4, CMS released Medicaid enrollment statistics through March 2015. Nearly 71.1 million were enrolled, which is more than 534,000 than were enrolled in February 2015.
  • CMS releases final rule updating the Medicare Shared Savings Program On June 4, CMS released a final rule updating the Medicare Shared Savings Program. Of note, the rule creates a new Track 3, based upon some of the successful features of the Pioneer ACO Model, which includes higher rates of shared savings, the prospective assignment of beneficiaries, and the opportunity to use new care coordination tools. Additionally, the rule streamlines the data sharing between CMS and ACOs, helping ACOs more easily access data on their patients in a secure way for quality improvement and care coordination that can drive critical improvements in beneficiaries’ care.

  • Other

    • Governors announce multi-state effort to address complex needs On June 16, the National Governors Association announced that Alaska, Colorado, Connecticut, Kentucky, Maryland, Michigan, Rhode Island, West Virginia, Wisconsin and Wyoming will participate in a policy academy designed to assist governors and their senior staff in establishing or enhancing programs that improve outcomes and reduce cost of health care for people with complex care needs.

    • Study addresses assistance to families addressing socio-economic factors On June 1, Pediatrics published a study, “Medical-Legal Strategies to Improve Infant Health Care: A Randomized Trial.” Researchers paired families of newborns with a family specialist who visited with the family during routine well visits, at one home visit, and during email, text and phone communications. At the time of their child’s birth, most of the study participants reported at least one hardship, such as food insecurity, housing concerns, or trouble paying utility bills, and many families had multiple hardships. Parents who were paired with a family specialist reported better success obtaining access to services such as utility assistance, food support programs and other resources. Researchers conclude the program offers a promising method of delivering services that improves the quality of preventive health care.
    • Insurers targeting members likely for hospital re-admission with extra services This article profiles insurance industry efforts to target members who are most likely to be re-admitted to hospitals. In this article, Independence Blue Cross shares that it runs algorithms which include billing claims, lab readings, medications, height, weight and family history; socio-economic factors are also included. From there, the insurer assigns a staff member to find extra services for the member.

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