A closer look at the CMS decision to suspend risk adjustment payments

Earlier this week, the Trump administration announced it would be suspending more than $10 billion in risk adjustment payments to issuers. Since then, several issuers and analysts have come out against the decision, saying CMS had several other options it could have taken.  

According to the Centers for Medicare & Medicaid Services (CMS), the hold is due to a March court ruling and pending litigation. The case involved New Mexico Connections, a consumer operated and oriented plan (CO-OP), which sued the Department of Health and Human Services (HHS) over an alleged flaw in the calculation that favored larger issuers. The presiding judge, James Browning, ruled that HHS’ formula was not illegal but should be re-examined. A previous court ruling in Massachusetts upheld the federal program.  

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The ACA’s vision of a reformed small-group market

Although the political controversy surrounding the Affordable Care Act has focused primarily on its extension of coverage through the individual market and Medicaid expansions, Congress also intended the ACA to reform extensively reform the small-group market. In the decade preceding the ACA, small-group health insurance premiums had more than doubled while the percentage of small firms offering coverage dropped from 66 to 59 percent. Administrative costs and employee cost sharing charges were high and benefits offered by some employers were skimpy. 

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Preparing for 2019 Open Enrollment: Softheon Enhanced Direct Enrollment (EDE) delivers a better consumer experience and enables new consumer self-service policy management capabilities

As health plans consider implementing and launching an EDE solution for ACA 2019 Open Enrollment, it’s become clear that EDE is much more than an improvement to the Marketplace (or on-exchange) enrollment process and post- enrollment policy management for consumers – it’s the beginning of a real-time, API driven service to promote an improved healthcare consumer insurance benefit shopping experience with online self-service updates.

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NMHIX: New Mexico State Health Insurance Exchange 2018 and beyond

New Mexico (beWellNM) is one of only five states that operates a state-based marketplace on the federal platform, more commonly known as SBM-FP. While this platform has proven to be successful for the last 5 years, the state has recently started looking to revitalize its exchange.

On December 13, 2012, New Mexico submitted a technical implementation letter to CMS to become a state-based health insurance exchange and was approved by CMS on January 3, 2013 to begin to follow and comply with state-based regulations. In an effort to grow into the healthcare era, NMHIX Centennial Care, New Mexico requested an extension on its current 1115 waiver, which is set to expire by December 31, 2018. The waiver, which will renew the state’s Medicaid managed care program, was sent to CMS on December 6, 2017. CMS has acknowledged the letter and confirmed that New Mexico’s extension application has met the requirements.

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Virginia Senate passes Medicaid Expansion

400,000 Virginians will soon benefit, following Wednesday’s decision by state legislature, to expand its Medicaid program.  

Virginia joins 32 states and the District of Columbia in expanding its public health insurance program under the Affordable Care Act. The new health care law, which is slated to take effect on January 1, would introduce changes to Virginia’s Medicaid program, which, according to reports, is one of the most “restrictive” in the nation.  

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New Jersey becomes second state to institute an individual mandate for health coverage

Shortly after announcing that the state will manage its own health insurance exchange for the 2019 Open Enrollment, New Jersey Governor Phil Murphy signed into law a bill enacting an individual mandate.

The bill, signed yesterday, requires all New Jersey residents to have health insurance coverage or pay a penalty. Democratic lawmakers drafted the bill in response to Congress’ decision to appeal the federal mandate established in the Affordable Care Act.

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Texas leads multi-state Affordable Care Act lawsuit

In February 2018, the attorney general of Texas, joined by attorneys general and governors from nineteen other Republican states, filed a lawsuit asking a Texas judge to invalidate the entire ACA.  

Their theory is that during a Supreme Court argument held in 2012, Congress lacked constitutional authority to enact the ACA’s individual responsibility requirement as a mandate, but upheld it as a tax. In 2017, Congress zeroed out the tax, thus, plaintiffs argue, the individual responsibility requirement now lacks any constitutional basis and is void. But, the argument continues, the individual responsibility requirement is key to all the rest of the ACA, so the entire ACA must be invalidated. In April, the plaintiff states (joined by two individual plaintiffs) asked the court to block the enforcement of the ACA and all associated regulations through a preliminary injunction. 

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CMS cautions non-expansion states about Medicaid work requirements

CMS Administrator Seema Verma is worried about a “subsidy cliff” in states that have not expanded Medicaid but are seeking to implement Medicaid work requirements.

The cliff impacts those who earn too much to qualify for Medicaid, but not enough to receive government subsidies. Verma is worried that if states without expanded Medicaid programs require recipients to get jobs, the added income will push them into this grey zone, leaving them without coverage.

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