Reports & Analysis

The Center for Consumer Information and Insurance Oversight has released a list of proposed 2017 Essential Health Benefits (EHB) benchmark plans for all 50 states and the District of Columbia. The Affordable Care Act (ACA) requires non-grandfathered health plans in the individual and small group markets to cover EHBs, which includes items and services in ten benefit categories. For plan year 2017, the EHB benchmark plan is a plan that was sold in 2014. CCIIO is accepting public comments on the proposed benchmark plans until September 30, 2015.

As the U.S. population ages, the need for long-term services and supports (LTSS) is increasing, and policy makers are grappling with how to finance this huge expense. The ACA included a plan to enhance the private market with a national voluntary long-term care insurance program, but Congress repealed it before it launched. Now, there is a flurry of activity as groups develop new financing approaches. This new Alliance for Health Reform toolkit explains the current LTSS system, trends in the delivery of care, and the current policy challenges.

This brief discusses the fact that payment reform focusing on value and quality is driving change that is redefining the hospital’s role in the continuum of care and the health of the broader population. This brief also identifies opportunities for state policymakers to encourage the evolution of hospital community benefit policy in ways that complement and support the realignment of the hospital business model, proactively address the social determinants of health, and ultimately improve the health of the entire community.

While the ACA afforded states the choice to host a health insurance exchange or expand Medicaid, it required all states to make major changes to Medicaid eligibility policy, including adding mandatory coverage of new groups, implementing streamlined eligibility and renewal processes, incorporating new eligibility and verification requirements, and coordinating enrollment systems with exchanges. As a result, states had to create or significantly modify existing systems, collaborate and coordinate with other state and federal agencies, and develop new processes to support enrollment. This brief examines states’ early experiences implementing the 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.

Born as an afterthought to Medicare five decades ago, Medicaid has evolved from an adjunct to state welfare programs to the nation’s largest health insurer. The occasion of Medicaid’s 50th birthday is a fitting time to consider that evolution, not to reminisce, but to help chart the path forward. Medicaid is a complex program with a complex history, and understanding its role in the U.S. health system is essential to ensuring that it is performing at optimal levels for its beneficiaries, as well as for states, taxpayers, and the myriad health care providers, health plans, and others touched by the program. In this four-part series, Cindy Mann and Deborah Bachrach of Manatt Health Solutions examine Medicaid’s evolution and consider its role in the new coverage paradigm established by the ACA.

As millions of Americans gain Medicaid coverage under the ACA, attention has focused on the access to care, quality of care, and financial protection that coverage provides. This analysis explores these questions by comparing the experiences of working-age adults with private insurance, Medicaid beneficiaries, and those who are uninsured. The survey findings suggest that Medicaid coverage provides access to care that in most aspects is comparable to private insurance. Adults with Medicaid coverage reported better care experiences on most measures than those who had been uninsured during the year. Medicaid beneficiaries also seem better protected from the cost of illness than are uninsured adults, as well as those with private coverage.

In the wake of the U.S. Supreme Court’s recent decision in King v. Burwell affirming the availability of federal subsidies to states opting to use the Federally-Facilitated Marketplace model, there is growing interest in state and federal marketplace options and performance. While states implementing both the FFM and SBM models had to overcome hurdles in building and managing multifaceted IT platforms, both are making significant progress in meeting the ACA’s coverage and access goals. However, the advancements and opportunities of SBMs are not as well-known as the challenges state and federal marketplaces have faced. This paper seeks to explore and highlight early developments in states that have implemented the SBM model.

A health insurance marketplace renewal process that accounts for both enrollee convenience and the changing value of financial assistance from year to year will likely play an important role in maintaining overall enrollment and long-term sustainability for state-based marketplaces. Through marketplace enrollment data and interviews with marketplace officials, insurer representatives and navigators, this paper examines how six state-based marketplaces experienced the first year of renewals. It finds that while the marketplaces approached renewals differently, they faced similar challenges, but were successful overall in retaining a substantial proportion of their 2014 enrollees.

Large bills from an out-of-network health care provider can be an unexpected surprise to consumers who did not knowingly obtain health care outside the plan’s provider network. As health plans embrace tighter networks as a tool for improving quality or reducing premiums, the potential for such bills may grow. Although insurers may protect their plan members in some cases, there is no broad protection from these types of bills in federal law or in most states. Several states have acted to protect consumers from the need to pay balance bills, at least in emergency situations. But even these states have struggled with how to implement protections while balancing legitimate interests of health plans and health care providers. This issue brief summarizes and compares seven state approaches to protecting consumers from balance billing.

One of the barriers to reaching consensus on significant payment reforms has been the complex and confusing array of terminology that has been used to describe different payment systems. It is difficult for stakeholders to determine whether to support a proposal if they do not understand the words and abbreviations used to describe it, and it is difficult to reach agreement when the same words are used by different people to mean different things or when words are perceived by some stakeholders to mean something different than what was actually intended. This Payment Reform Glossary is designed to facilitate a better understanding of payment reform concepts and to create a foundation for a common language for developing and discussing payment reform concepts so they can be supported and implemented by all stakeholders — patients, providers, employers, health plans, and government agencies.