CBO: 6 Million More People Will Be Insured Through an Association Health Plan or Short-Term Plan in 5 Years

Over the next five years, association health plans and short-term plans will gain about 6 million additional enrollees according to a new estimate by the Congressional Budget Office and Joint Committee on Taxation.


When association health plans and short-term plans federal rules are fully phased in, about 4 million people will choose an association health plan and another 2 are predicted to be in a short-term plan of 12-months duration. With an association health plan, employers could band together to jointly offer coverage that does not meet minimum standards for benefits that "insurers small group or non-group markets must provide."

Healthcare Finance predicted that since younger, healthier individuals would probably join the short-term plans and depart the small group and non-group markets.  This may result in premium hikes for those left in those plans by 2 to 3 percent, CBO estimates. 

Premiums for benchmark plans are expected to increase about 15% by next year and 7% per year between 2019 and 2028. According to healthcare finance, Federal subsidies for those who are insured will total $685 billion this year and will reach $1.2 trillion in 2028. Medicaid and CHIP will account for 40% of the total as well subsides from tax benefits. 

The CBO also estimated that administration's budget will reduce mandatory federal spending for health care by $1.3 trillion, or 8% every year for the next ten years. In addition, the budget would repeal the ACA expansion of Medicaid coverage, cap Medicaid spending on a per-enrollee basis, cap damages in medical liability system, and require Medicare Part D beneficiaries to pay higher out-of-pocket expenses for some prescription drugs. 


Providers Overpaid: Medicare's Multimillion-dollar Mistake

The Centers for Medicare and Medcaid Services told Georgia Health News last Wednesday that the agency is seeking to recoup nearly $55 million from hospitals and other medical providers in Georgia and other surrounding states, citing contractor errors. The agency found nearly 268,000 claims from hospitals, rural health clinics, and other providers that mistakenly paid though the traditional fee-for-service Medicare program. The agency also sated that "the patients served in these instances were members of a Medicare Advantage program and they were run by private insurers, and that hospitals should have been paid by those health plans instead". 

The states affected are Georgia (owes $19.1 million), Tennessee ($15.4 million) and Alabama ($11.9 million), and another $8.3 million from other states. 


Among rural providers, Upson Regional Medical Center in Thomaston, GA owes the feds $254,000. The recoupment involves more than 1,400 claims from May 2014 to May 2018. The hospital executive, Sallie Barker, stated "Hospitals are being Penalized for someone else's mistake" and that she had asked questions but wasn't getting any answers. HomeTown Health, an association of rural hosptials in Georgia says their repayments from its members could range from $3,000 to $254,000.

For hospitals struggling with cash flow, a takeback can create a big problem. When you’re given a mandate, you’ve got to figure out how to pay it.
— Jimmy Lewis, CEO, HomeTown Health

The medical providers had until a tight deadline of July 1st for repayment but CMS announced that it extended the planned repayment by two weeks to "allow providers time to research the issue and provide documentaion showing they do not owe the funds". 

CMS to Increase Oversight of Medicaid Enrollment and Managed Care Plans

According to Modern Healthcare, CMS announced Last Tuesday that will be heightening audits to "confirm that Medicaid beneficiaries are correctly identified as expansion or pre-expansion enrollees". States receive higher federal match rates of around 90% for expansion enrollees, while the match rate can be as low as 50% for pre-expansion enrollees.


This imbalance in the federal matching rate creates financial risks for taxpayers by incentivizing states to shift cost to the federal government.
— Seema Verma, CMS Administrator

CMS will also audit states that are at high risk for enrolling ineligible people in Medicaid. In the past, states like California, Kentucky, and New York have been cited by the OIG for doing so.

This strategy is a multi-faceted plan to reduce improper payments within the Medicaid program. That includes fraudulent claims, payments distributed to the wrong recipient or for the wrong amount, payments with insufficient documentation and cases when recipient uses the funds improperly. Matt Salo, Executive Director of the National Association of Medicaid Directors stated he doesn't have a reason to believe there is any more fraud, waste, and abuse than there was 20 years ago but it is important to be 'constantly vigilant'.

CMS also intends to take a closer look at Medicaid managed care plans to ensure they are complying with medical loss ratio standards. The agency set a rule in 2016 that sets the medical loss ratio at 85%, meaning all insurers must spend at least 85% of their Medicaid revenue on medical care and other activities that will improve quality. The remaining 15% can be spent on salaries, marketing, profits, or other administrative tasks. If plans do not meet the 85% standard, they will have their state rates lowered in the future. 

CMS to Test Offering Medicare Advantage as Another Track Under QPP

According to Modern Healthcare, CMS wants to lunch "an experiment that allows doctors in Medicare Advantage plans to qualify as participating in an alternative payment model (APM). 


For a brief reminder of the Quality Payment Program, clinicians have two tracks to choose from: MIPS, which requires clinicians to report and meet quality goals and APM, which require clinicians to take on financial risk as part of their efforts to improve care and lower costs. They clinicians meet the goals under an APM, they are eligible for bonuses. 

Clinicians in Medicare Advantage plans have urged CMS to consider those plans as APMs since some are offering risk-based contracts. When clinicians participate in an APM, they must receive a certain amount of Medicare fee-for-service revenue, but for some providers who primarily see Medicare Advantage patients, that threshold may be too high. 

Previously, CMS would have launched a five-year demonstration year. They would have asked providers about the payment arrangements they had with Medicare Advantage plans and the number of patients covered under those arrangements. That information will determine whether the payment arrangement will meet the risk standards to count as an APM. 

However, Seema Verma announced late today that they would offer another choice, Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI). MAQI comes as an option as CMS stated there are not enough alternative payment model (APM) options to avoid MIPS requirements. 

MA enrollment is projected to grow to 9% in 2018, which will bring total enrollment to 20.4 million lives. CMS estimated that more than one-thirds of all Medicare enrollees will be in a Medicare Advantage plan in 2018. 

American Cancer Society Recommends Colon Screenings Should Start at 45, not 50

New guidelines released recommend that Colon cancer screenings should start at age 45, instead of the previously recommended age of 50 for U.S. adults. American Cancer Society's advice came after a study published last year found a rising rates of color cancer and deaths in people younger than 50. Experts aren't sure why there is a 50% increase in cases since 1994. The advice also puts American Cancer Society out of sync with guidelines from an influential government advisory group, which kept the screening age at 50 since it was updated 2 years ago. 

The guidelines are for men and women ages 45 to 75 of average risk for colon cancer; recommendations are different for people with certain conditions, like Crohn’s disease, or a family history of colon cancer. The group endorses six kinds of screening exams, from inexpensive take-home stool tests performed every year to colonoscopies done every 10.
— Associated Press

Most colon cancer occurs in adults 55 or older, but the rate of cases and deaths have thankfully been falling for decades. Colon cancer, combined with rectal cancer, is the second leading cause of cancer death in the U.S., falling in line after Lung cancer. This year alone, more than 140,000 Americans are expected to be diagnosed with it and about 50,000 will die from it. 

Doctors may have to look into specialty medical societies to sort out the different guidelines, as experts are worried about pre-50 colon cancer in some racial and ethnic groups. On the other side, people have argued that instead of lowering the age to 45, more effort could be put into getting more people tested, since only two-thirds of the population have been following screening guidelines. Dr. Andrew Wolf, lead author of the new guidelines, suggested that they should be able to do both - lower the age and get more of the population to follow screening guidelines. 


FCC Chairman calls for Increase in Rural Health Care Program Funding


Federal Communications Commission Chairman Ajit Pai drafted an order to his colleagues to increase the annual funding cap by nearly 43%, from $400 million to $571 million for the Rural Health Care Program. The program provides telecommunications and broadband services to rural communities that support telemedicine. If approved, the $171 million increase would take effect immediately to address funding shortfalls and improve telemedicine care in rural areas. 


This money will help healthcare providers get the connectivity they need to better serve patients throughout rural America. Demand for funding has been outpacing the program’s funding cap, so I also believe that the increased cap should apply to the current funding year so that rural healthcare providers can be fully reimbursed.
— Ajit Pai

In 1996, Congress mandated that the FCC use Universal Service Fund to support telecommunications and information services to eligible providers in rural communities to enable telemedicine, transmit health records, and conduct telehealth activities. However, the cap for the Rural health Care Program was never inflated since it was set in 1997, causing the funding to outpace the budget. 

According to Health Data Management, 31 senators warned Pai that unless the spending cap is raised appropriately to current and future needs, the providers may experience severe rate increases for their services, making it harder for rural practitioners to engage in life-saving telemedicine. On the other hand, American Hospital Association concurs that the Rural Health Care Program needs to be updated and the funding is critical to improve lives of rural Americans. Pai is hoping his colleagues will support the funding increase and prevent delay. 

Piedmont Health Becomes Out-of-Network with BCBS


As of April 1st, Piedmont Health became out-of-network with the largest insurance company in the state of Georgia, Blue Cross Blue Shield (BCBS). The two organizations were unable to reach an agreement on a new contract, therefore causing the current contract to lapse. Piedmont Health is a rapidly expanding healthcare system based out of Atlanta; who currently have 11 hospitals across the state.

Who is Affected?
Since an agreement was not reached, any individual carrying BCBS plans cannot visit Piedmont Health facilities without going out-of-network. The affects not only the public, but also the over 550,000 State of Georgia, and University System employees. For the patients that have BCBS they can still have many options for receiving care. They can go to another in-network doctor, or if they need emergency care they can still go to a Piedmont Health Hospital. Emergency care is always covered benefit, regardless of the network status of a hospital.

What Patients Can Do for Care
Emergency care is not the only remaining coverage between BCBS, and Piedmont Health. The dissolution of these two companies does not affect all plans. Any patient that has a Blue Cross Blue Shield MA plan can still have continuation of coverage. BCBS A state law protects patient that have a chronic or terminal illness continuous care for 60 days after the termination of an agreement. Also pregnant women can continue to see their physician throughout the entire length of their pregnancy, and six weeks after childbirth.

Will it be fixed?
With Piedmont Health, and Blue Cross Blue Shield temporarily dissolving their relationship. This leaves many across the state with less options when it comes to seeking care. However, now that the contract has passed its termination date it puts more pressure on both Blue Cross Blue Shield and Piedmont Health to pass a new agreement.

To learn more about this topic see below.

Source: Out of Time and Our of Network: Piedmont, Blue Cross fail to reach deal by Andy Miller, Georgia Health News. Posted April, 1st 2018

Capitol Watch 2018 - Session Summary

Capitol Watch 2018 Session.png

Good afternoon,

The 2018 legislative session drew to a close March 29th shortly after midnight. The final day was marked by numerous twists and turns, bill substitutions, and conference committees.  
In the end, all health care bills failed to move due to political gamesmanship. Both the House and the Senate dug in their heels over APRN issues and all other measures were casualties. We can report that no damaging legislation passed; however, many good public policy measures fell short.  

 Onward and upward--looking forward, we have much to do in the interim with our legislative champions. As a reminder, major change is coming as next year we will be dealing with many new legislators and a new Governor as well.  
Thank you to everyone that took time to visit the Capitol, write, email, or call elected officials this year.

Please click the button below for the full legislative session summary.


Reports: Walmart Looks To Acquire Insurer Humana

According to the Wall Street Journal, Walmart is in preliminary talks to buy insurer Humana.

Walmart Humana.png

Walmart started to sink their feet into healthcare by being a drugstore operator, as well as operating some retail clinics. The retail giant hopes to take advantage of Humana's Medicare Advantage business as more baby boomers become eligible for that program. 

Though the Wall Street Journal did not disclose how much the deal would be worth, Walmart is one of the nation's largest private employers with more than 1.5 million workers and a market value of $260 billion. Humana, on the other hand, is one of the country's largest insurers with a market value of $37 billion, with 52,000 employees. 

If the Walmart and Humana deal shows to be true, they would be joining the series of other deals that would bring retailers into the healthcare space. Last year, CVS agreed to buy Aetna for $69 billion and earlier this month, Cigna agreed to buy Express Scripts Holding for $53 billion.

Keep coming back for more updates on this possible merger. 


Bill Would Let ‘Micro-Hospitals’ In Rural Georgia Counties

Last Thursday, The Georgia Senate passed a bill that aimed at helping rural hospitals that are struggling to stay open. According to WABE, the bill includes provisions to allow “micro-hospitals” in rural counties. Micro-hospitals are are a 24/7, small-scale inpatient facility with up to ten inpatient beds used for observation and short-stay use.

When a rural hospitals closes, the bill would allow a neighboring county hospital can purchase the building and turn it into a micro-hospital. So how often are rural hospital closures? In the last 6 years, Georgia has seen six rural hospitals close their doors.

Senator Dean Burke, who sponsored the bill, stated that though we most likely won’t be 30 micro-hospitals pop up in the next five years, “there might be five or six that gives rural citizens in those counties access they otherwise would lose”.

The bill would also maximize the value of tax credits a person or company can get when they donate to a rural hospital though a tax credit program established two years ago. It would also create grant opportunities to incentivize doctors to work in underserved communities and help with medical malpractice insurance.

Because the senate made changes to the legislative, the bill will go back to the House for agreement.

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