Medicaid waivers have historically allowed states to experiment with delivery reform and coverage expansion, but increased in popularity in 2012 following a United States Supreme Court decision. This decision was related to the states’ choice on whether to expand their Medicaid programs to cover individuals with incomes of up to 138% of the federal poverty level.
During the Obamacare Administration, states’ requests for waivers were denied. This included those which:
- would have conditioned Medicaid eligible for some beneficiaries on their ability to find work;
- waivers that would have terminated coverage for beneficiaries with incomes below the poverty level if they failed to make out-of-pocket payments for medical care; and
- state requests to partially expand their Medicaid programs to enroll beneficiaries with incomes up to 100% of the poverty level, but not those between 100% and 138%.
According to research, many factors impact insurance choices, including network size and brand, but price is the biggest factor.
Insurers in the market are facing new uncertainties with the current political environment. The fate of the individual mandate, which helps to reduce premiums by compelling healthy people to purchase insurance, and the continuation of cost-sharing reduction (CSR) payments, have been concerning factors in the 2018 rate filings.
With continued uncertainty in Washington and the seemingly overwhelming media reports, the industry awaits to learn the fate of the Affordable Care Act (ACA). Whatever the result, this situation has caused the healthcare payer community to identify new ways of securing their membership amid market forces, such as competition, consumerism, and policy changes. It has driven the need for innovative solutions that exceed consumer expectations, further amplifying the focus placed on the consumer. According to Strategy&, it is [that] are driving a transformation among healthcare consumers,” and market focuses such as these.
According to Gartner, “at a minimum, all healthcare organizations should adapt and improve consumer engagement incrementally within the context of an overall engagement strategy…However, the minimum is not enough to remain competitive, even in the near future, as both traditional and nontraditional healthcare companies increasingly compete on the basis of consumer engagement.”
We’re thrilled to announce that for the seventh year, Softheon has been recognized in Gartner’s 2017 Hype Cycle for Healthcare Payers, which tracks the maturity and adoption rates of various technologies within the healthcare payer industry.
For 2017, we have been named a sample vendor in the areas of Private Exchange Technology and Retail Analytics for Healthcare Payer, a new category which covers analytics oriented around members and prospects, member lifetime value, and “member next-best action.”
States’ approach to modularity and MITA compliance
With over 74,550,529 Medicaid and CHIP beneficiaries, these programs have evolved to become highly complex, multibillion-dollar enterprises. Initially, Medicaid Management Information Systems (MMIS) were designed as a financial and accounting system for paying provider claims accurately and timely. However, Medicaid programs have grown in complexity, and MMIS have developed to accommodate these new complexities.
According to the Centers for Medicare and Medicaid Services (CMS), “MMIS – once defined as a single, integrated system of claims processing and information retrieval – is being redefined under Medicaid Information Technology Architecture (MITA) as the new “virtual MMIS” to most, if not all, of the additional non-financial Medicaid systems running on multiple hardware and software platforms.”
CMS will allow some to skip HealthCare.gov during the 2018 Open Enrollment Period (OEP).
On May 17, 2017, the Department of Health and Human Services and the Centers for Medicare and Medicaid Services announced a new “Proxy Direct Enrollment (DE) Pathway” for the 2018 Open Enrollment Period (OEP).
Initially this process will be available for simple enrollments only, rather than special enrollments, terminations, or such as multi-tax filer households or applications with non-United States-born citizens. Consumers will also need to create their own HealthCare.gov account to engage in the process . For the 2018 open enrollment period, DE Proxy will be available for the Federally Facilitated Marketplace (FFM) and State-based Marketplaces (SBMs) utilizing the Federal HealthCare.gov platform. Applicants and enrollees using the process will be able to complete their eligibility determinations – including eligibility determination of marketplace coverage, premium tax credit, and cost-sharing reduction payment – and enroll in qualified health plans (QHP) on the direct enrollment entity’s website .
Since the beginning of this year, multiple bills have been introduced to “repeal and replace” the Affordable Care Act. Here’s a look at the some of the re-reform efforts we have seen this year:
Vice President Mike Pence and CMS Administrator Seema Verma both had a significant role in shaping the way Indiana has structured and increased access to Medicaid through Healthy Indiana Plan 2.0. The program, which is up for renewal, may be used as a model for other states as they look to utilize waivers to individualize their programs.
For the last six years, the Healthy Indiana Plan (HIP) has delivered quality care, encouraged the use of preventive services, and received measurable results. This Medicaid expansion project became the first in the nation to adopt and successfully demonstrate the linkage of personal responsibility with subsided health coverage to low-income individuals. It accomplished this by incorporating the concepts of a high deductible health plan with the concepts of a health savings account (HSA).
With the future state of health care uncertain, States are displaying their continued interest in healthcare reform to address their states’ health care needs with Section 1332 State Innovation Waivers.
Perhaps less well known than Section 1115 Waivers, Section 1332 Waivers allows states to pursue innovative strategies for providing residents with access to quality, affordable insurance while retaining basic protections of the Affordable Care Act (ACA). Section 1332 Waivers became available through the ACA on January 1, 2017, as a way to permit states to pursue new strategies to provide quality health insurance, while preserving basic protections of the ACA.
The Senate unveiled the Better Care Reconciliation Act of 2017 (H.R. 1628) on June 22, a bill that would effectively repeal and replace the Affordable Care Act and introduce a number of provisions impacting how more than 12.7 million people obtain health insurance. The bill would also grant small businesses and associations the ability to establish small business health plans that operate outside of state insurance regulations.
These association health plans (AHPs), also known as group trusts, multiple employer welfare associations (MEWAs), or Small Business Health Plans (SBHPs), would provide more than 28.5 million small employers with the option to offer competitive and affordable health benefits to employees and maintain common benefits across state lines. This would be achieved when small businesses with healthy employees join associations and sign up for plans with fewer benefits and lower premiums. This in turn would allow cost savings to be passed down to their employees along with heightened purchasing power. An example of this could involve a group of restaurants that form a restaurant association and purchase insurance as a group.