Author: Sean Kirschner

What’s new for SHOP in 2018

The Small Business Health Options Program (SHOP) will remain open for small businesses with 1-50 employees in 2018, and will boast new features that’ll impact how small employers and their employees enroll in and manage their coverage for SHOP plans starting on or after January 1, 2018.

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CMS signals support for Medicaid work requirements

Earlier this month, the head of the Centers for Medicare and Medicaid Services (CMS), Seema Verma, made an announcement conveying that CMS would approve waiver applications from states that would require Medicaid enrollees to participate in “community engagement” activities, otherwise known as work requirements. This follows a letter co-authored by Verma that encouraged state Medicaid directors to use these waivers to modify their Medicaid programs to empower consumers. To advocates, work requirements are a way to empower Medicaid enrollees by encouraging them to be independent, self-sufficient consumers of healthcare.

Here’s what you should know about the proposed work requirements for Medicaid:

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Major changes to 1332 waivers could be coming

1332 waivers, or state innovation waivers, allow states to apply to the federal government to waive certain provisions of the Affordable Care Act (ACA) and pursue innovative strategies for providing residents with access to quality, affordable insurance while retaining the law’s basic protections. However, there are two developments currently in motion that could make significant changes to these waivers.

One is the Alexander-Murray bill, which is indirectly connected to the Congressional tax bill currently in the process of reconciliation between the Senate and the House. The other is a bill currently being drafted by Senators Orrin Hatch (R-UT) and Mike Crapo (R-ID) that would overhaul the 1332 process, altering many of the original stipulations laid out by the ACA.

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Hidden benefits of medicaid expansion

Although there is still an ongoing debate in many states over whether or not to expand Medicaid, in the 33 states that have, unexpected benefits are starting to surface.

When the Patient Protection and Affordable Care Act (ACA) laid the framework for Medicaid Expansion, it allowed states to expand the income level needed to qualify for Medicaid. This gave a large number of Americans access to coverage. But it turns out this wasn’t the only benefit.

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A Guide to the 2017 SHOP Guaranteed Availability Window

While small businesses can enroll in the Small Business Health Options Program (SHOP) at any time, today kicks off a month-long guaranteed availability window that allows small businesses to enroll in SHOP plans without meeting the usual requirements.

Starting today, the Federally facilitated SHOP (FF-SHOP) on is closed. Small businesses in FF-SHOP states will not be able to enroll online (though they will still be able to check their eligibility online). From now on, these small businesses will have to use a broker or agent to enroll in SHOP, or, alternatively, they can enroll directly with a health plan.

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A Victory for Maine Medicaid Could Be an Inspiration to Others

What happened?

In a first-of-its-kind vote, Maine residents elected to expand the state’s Medicaid program through a state-wide referendum on Tuesday, November 7.

The expansion easily passed with 59% of voters in favor. These results place a majority of Maine residents in opposition to the stance of their Governor, Paul LePage, who has vetoed five bills to expand Medicaid.

Maine was one of 19 states that did not initially expand Medicaid in reaction to the Patient Protection and Affordable Care Act (ACA) in 2010. The state previously expanded the program in 2003, increasing the eligible population and subsidizing private coverage, but LePage dismantled much of this framework when he took office in 2011.

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Three States Bar Issuers from Increasing Rates

UPDATE: On October 26th, North Dakota’s insurance commissioner announced that Sanford Health Plan will return to ND’s individual exchange for 2018, but only in 5 counties. Sanford’s Executive Vice President, Kirk Zimmer stated that the move was due to the Trump administration’s decision to cut off insurer subsidies.

Though the start of the 2018 Open Enrollment Period (OEP) is only a week away, there is unprecedented uncertainty around the Exchanges and federal funding established by the Patient Protection and Affordable Care Act (ACA). Despite this, three states have decided to hold their ground and block issuers from increasing member premiums for 2018.  

With rumors that the White House was considering ending cost-sharing reduction payments, many health insurance carriers increased their 2018 premium rates to account for the loss of government funding. Since the official decision to end the payments on October 12, even more health plans have raised their rates through an informal offer by the Department of Health and Human Services (HHS), allowing carriers to adjust their premium rates right up until OEP 2018 on November 1st (1).  

While insurers in all 50 states, plus D.C., have requested the approval of rate hikes, the insurance commissioners of Minnesota, North Dakota, and Vermont have unilaterally declared that they will deny any such request by insurers participating in their exchanges. They reason that the effect would be too severe with such little time until OEP 2018 begins on November 1st, justifying that their purpose is to protect consumers though whatever measures they can take. 

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Despite Challenges and Inefficiencies, SHOP Empowers Businesses to Obtain Coverage

In accordance with its goal of reducing the country’s uninsured rate, The Affordable Care Act (ACA) established the Small Business Health Options Program (SHOP) to create a small business insurance marketplace. SHOP’s purpose was to provide small businesses with unprecedented access to health insurance coverage for their employees, which was traditionally difficult due to their limited size. By setting up an exchange specifically for small businesses separate from the group and individual markets, SHOP tried to reach out and empower businesses that did not have the means to obtain coverage previously.  

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Graham-Cassidy: A Closer Look

There is a major effort in Washington to push healthcare reform through before the end of the September.

The new bill drafted by Sen. Lindsey Graham (R-SC) and Sen. Bill Cassidy (R-LA) is appropriately known as the Graham-Cassidy bill. It is lauded by its sponsors as a proposal to return power to the states after the centralization of the ACA. Under the Graham-Cassidy bill, money made available for Medicaid Expansion effort and health plan subsidies would be pooled and allocated to states as block grants, which the states can then use to build their own health care plans. The block grants will be based on the number of individuals with incomes between 50-138% of the Federal Poverty Line (FPL) in the state, but this is only initially. Starting in 2024, enrollment levels will also be factored in to determine the level of funding available through the grants. Block grants are only provisioned through 2026, though, with nothing legislated to take their place after that year.

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Do Third Party Payments Adversely Affect Consumers?

As we explored earlier in this series, third party premium payments negatively impact stakeholders in the healthcare system – and consumers are no exception. For consumers, the largest barrier to healthcare today continues to involve the cost of care, prescriptions, and insurance. As of February 2017, 29% of consumers say they had a problem paying medical bills in the last 12 months, which led some to seek financial assistance through third parties.

For most, the concept of third party payments is foreign. Consumers are introduced to these payments though healthcare providers presenting them as a solution to afford premiums for treatment. Providers advise patients on their coverage options between private insurance and Medicaid (if eligible), and connect with nonprofit charities to present them with patients that are in need of financial assistance. However, there has been some controversy surrounding this system. These involve accusations of fraudulent practices with lawsuits between insurers and providers that leave patients vulnerable in the cross-fire.

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