Reports & Analysis

Provider groups taking on risk for the overall costs of care in accountable care organizations are developing care management programs to improve care and thereby control costs. Many such programs target “high-need, high-cost” patients – those with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges. This study compares the operational approaches of 18 successful complex care management programs in order to offer guidance to providers, payers, and policymakers on best practices for complex care management.
 

States have taken different approaches to implementing the Affordable Care Act (ACA) and have had varied enrollment experiences to date. This brief highlights the experiences of four states—Colorado, Connecticut, Kentucky, and Washington—that established a State-based Marketplace (SBM), implemented the ACA’s Medicaid expansion, and achieved success enrolling eligible individuals into coverage. Based on interviews with key stakeholders in each state, it identifies effective strategies that contributed to enrollment and current priorities looking forward.
 

Three months after the first Marketplace open enrollment period closed, 13.9 percent of adults still remain uninsured as of June 2014. This brief assesses the demographic and socioeconomic characteristics of the remaining uninsured, their access to employer-sponsored insurance (ESI), their awareness of key ACA provisions, and the reasons they say they remain uninsured. This early look at the characteristics of the remaining uninsured provides valuable information for ongoing Medicaid outreach and enrollment efforts, as well as preparations for the next open enrollment period in the Marketplaces.
 

Navigators and others helping people apply for health coverage need to understand basic tax filing rules because eligibility for Medicaid, the Children’s Health Insurance Program (CHIP), and premium tax credits for coverage bought through Marketplaces is based on Internal Revenue Code definitions of income and household. The guide provides basic information on relevant tax rules, including when someone is required to file taxes, what filing status options are available, the rules for claiming someone as a tax dependent, and what sources of income are taxable and therefore counted in determining eligibility for Medicaid, CHIP, and premium tax credits.  It also shows how Medicaid uses an individual’s tax filing status to determine who is in his or her household, and how Medicaid’s household rules differ from those used for premium tax credits.
 

High-performing health plans are critical to the success of efforts to align Medicare and Medicaid services, including the capitated financial alignment demonstrations as well as Dual Eligible Special Needs Plans. Yet, there is little consensus about what makes an integrated health plan high-performing. This brief introduces a framework of key attributes of high-performing health plans. While the framework is intended as a guide rather than a set of formal criteria, it can help states and health plans establish the elements essential to successfully providing coordinated, person-centered, integrated care that meets the needs of individuals with complex needs.
 

Medicaid is the largest health insurance program in the United States, covering both acute and long-term care services for over 66 million low-income Americans. Medicaid is currently undergoing its biggest change since its inception due to the implementation of the ACA. These changes will affect which individuals—and how many—may enroll in the program and how care is delivered. Policymakers in the 50 states and the District of Columbia, cautious about Medicaid’s claim on state revenue, need to know how the changes will affect state budgets and residents’ health. This report, the first in a series, focuses on the impact of Medicaid on the states, including trends in spending and enrollment, and the anticipated effects of the ACA.

Under the ACA, the health insurance marketplaces have a variety of mechanisms through which they can drive improvements in health care quality. This issue brief reviews actions taken by State-based Marketplaces (SBMs) to improve health care quality in three areas: 1) using selective contracting to drive quality and delivery system reforms; 2) informing consumers about plan quality; and 3) collecting data to inform quality improvement. Thirteen SBMs took action to promote quality improvement and delivery system reforms through their marketplaces in 2014. Although technical and operational challenges remain, marketplaces have the potential to drive system-wide changes in health care delivery.
 

This report examines the experience of Assister Programs across the states to conduct outreach and enrollment assistance during the first open enrollment period for the Marketplaces. Based on responses to this survey, this report offers the first nationwide assessment of the number and type of Assister Programs and the number of people they helped. This report also examines the nature of help consumers needed, both pre- and post-enrollment, and the extent to which Assister Programs could meet consumer needs.  In addition, it discusses key factors that impacted the effectiveness of Assister Programs at the outset and the outlook for consumer assistance in the future.
 

To better understand the nature of coverage available to consumers through the Exchanges, Breakaway Policy Strategies partnered with the Robert Wood Johnson Foundation to collect detailed information on premiums, network composition, deductibles, out-of-pocket limits, and cost-sharing for every 2014 Silver Exchange plan in all 50 states and the District of Columbia. This report takes a closer look at cost-sharing for primary care physician (PCP) and specialist visits, including application of plan deductibles, copayment and coinsurance amounts, and the unique plan design features that may lead some enrollees to think twice before scheduling their next appointment with a doctor.
 

As rate filings for 2015 Affordable Care Act (ACA) health plans become public, virtually all media attention has focused on premium changes. What have been ignored are the changes in the plans’ out-of-pocket expenses. Inasmuch as deductibles and physician fees have the potential to add thousands of dollars in annual healthcare expenses, media disregard of health plan cost-sharing is especially unhelpful to the portion of the public who uses healthcare services regularly. This report examines major out-of-pocket cost categories within public rate filings for 2015 Affordable Care Act plans in 9 states.