Catalyst Center Week in Review.

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"Confusion is the hallmark of a transition."

- Anne Grant

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By Bob Rosenblatt
February 27, 2012
Los Angeles Times
Employer-sponsored health insurance originated during World War II when Henry J. Kaiser, founder of the Henry J. Kaiser Family Foundation, offered insurance as an incentive to attract employees and to keep them healthy and fit enough to build navy ships at his California shipyards. Thus began the convention of employer-sponsored health benefits, which distinguishes the United States from other industrialized countries where governments use taxes to provide health care for all, regardless of employment status, "as a basic right of modern society."

Health care reform might seem like a new idea, but it's not. Presidents Franklin Roosevelt and Harry Truman tried and failed to implement national health insurance. The Internal Revenue Service (IRS) helped perpetuate employer-sponsored health insurance by exempting up to 5% of benefits from taxable income. In 1965, the federal government entered the health care arena when President Johnson helped create Medicare and Medicaid. According to this article, this may be why the individual mandate provision of the Affordable Care Act (ACA) is perceived as a government takeover of health care, rather than as an expansion of both publicly funded health benefits and the private health insurance market.

By Michelle Diament
Disability Scoop
March 1, 2012
The National Conference of State Legislators reports that at least 29 states have autism mandates, which require health insurers to cover specific services for individuals with autism. An additional five states have laws that require insurers to cover a limited number of autism services as part of their plan's mental health benefits. This article reports the results of a survey conducted by Autism Speaks and MedClaims Liaison, a private, for-profit patient advocacy company. More than 25% of the 900+ families that participated in the survey - all with family members with autism and all living in states that require insurers to cover autism services - said they did not know about their states' requirements for coverage. Half of the families said the providers their family member needed did not accept their insurance. Disability Scoop reports Peter Bell, executive vice president of programs and services at Autism Speaks, as stating that autism legislation is not enough to ensure individuals receive needed services, and that there must be a focus on "implementation and enforcement."

By Larry Levitt, Gary Claxton, and Karen Pollitz
Notes on Health Insurance and Reform
Henry J. Kaiser Family Foundation Health Reform Source
February 28, 2012
In 2014, the Affordable Care Act (ACA) will require individual and small group private health insurance plans, in and out of the Exchanges, to provide essential health benefits and to conform to certain standards for cost-sharing. This article, from the Henry J. Kaiser Family Foundation Health Reform Source, provides an overview of recent guidance from the U.S. Department of Health and Human Services (HHS) about these two consumer protections. Read a synopsis of the HHS essential health benefits guidance issued on February 17, 2012. The following week, HHS released guidance about consumer cost-sharing, which explains the options health insurers have for determining "actuarial value (AV)," which is the percent of costs a plan will cover. Insurers can create up to four plan types, nicknamed the "heavy metal" plans. Platinum plans have a 90% AV; they will cover 90% of the costs of care and consumers will pay 10%. The AV for gold plans is 80%, silver is 70%, and bronze is 60% AV; consumers will pay 20%, 30%, and 40% of the costs, respectively. However, the guidance does not specifically prohibit plans from limiting medications or services for individuals with complex health needs, and is not clear about documentation that will make it easy for consumers to compare plans and cost-sharing.

By the Kaiser Initiative on Health Reform and Private Insurance
February 29, 2012
The Medical Loss Ratio (MLR) is a provision of the Affordable Care Act (ACA) that requires health insurers to maximize the amount of consumers' premiums they spend on health care, quality improvement, and other activities, and minimize profits and money spent on administration and marketing. Even before this provision took effect in 2011, 70% of small group and 77% of large group insurers met the required 80/20 and 85/15 MLR ratio, respectively. The individual insurance market has a lot of catching up to do, as only 43% met the MLR requirement in 2010. With the exception of self-funded employers, who are not considered health insurers because they incur the liability for their employee's health services, the MLR provision applies to all health insurers, including grandfathered plans. If a health insurer did not meet the MLR in 2011, they must provide refunds to the employer and employees in 2012. In subsequent years, rebates will be calculated based on an insurer's performance over three years. This fact sheet from the Kaiser Initiative on Health Reform and Private Insurance provides details about the MLR equation and adjustments based on a plan's enrollment. There is also a list of states to which the U.S. Department of Health and Human Services (HHS) granted MLR waivers. HHS may require insurers to report MLR every year; currently they only have to report it for years when they are out of compliance.


The Henry J. Kaiser Family Foundation
January 2012
Visit Disenrollment Policies for Non-Payment of Premiums in Children's Coverage to see each state's policy about discontinuing a child's Children's Health Insurance Program (CHIP) eligibility due to non-payment of premiums. Find the most recent Federal Medical Assistance Percentage (FMAP), and learn how each state is integrating and upgrading its Medicaid and CHIP Eligibility Systems. These data, and more, collected during a national survey by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families are published in Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Practices in Medicaid and CHIP, 2011-2012.

R2Implications of Health Reform for American Indian and Alaska Native Populationslink2  
Carolyn Ingram, Shannon M. McMahon, and Veronica Guerra, Center for Health Care Strategies, Inc., and Alice Weiss, National Academy for State Health Policy
February 2012
One of the broad goals of the Affordable Care Act (ACA) is to help reduce racial and ethnic disparities in health care by collecting data about race, ethnicity, and language; researching health and health care disparities; promoting workforce diversity; and supporting skill-building programs about cultural competency for health care providers. This policy brief, developed by the Center for Health Care Strategies, Inc. and the National Academy for State Health Policy for the Robert Wood Johnson Foundation's State Health Reform Assistance Network, discusses specific provisions of the ACA that will work to reduce health disparities for American Indians and Alaskan Natives (AI/ANs). These include:
  • Exemption from the mandate to purchase minimum health care coverage;
  • Ability to change health plans purchased within a State Health Exchange as often as once a month, while other consumers can only change plans once a year;
  • Families with income less than 300% of the federal poverty level will not pay deductibles and co-pays;
  • AI/AN tribes that have "established relationships with employers and employees" will qualify for grants to be Exchange Navigators, thus ensuring tribal members will receive culturally and linguistically competent information about access to health care;
  • Indian Health Services, Tribal providers, and urban Indian organizations can be Express Lane Agencies to facilitate enrollment of eligible children in Medicaid and the Children's Health Insurance Program (CHIP).
R3Abstract: Patient-Centered Medical Homes Offer a Model for Better, Cheaper Health Carelink2  
By Mike Mitka
The Journal of the American Medical Association (JAMA)
February 22/29, 2012
In February 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association created the Joint Principles of the Patient-Centered Medical Home. Five years later, the Center for Medicare and Medicaid Services (CMS) and the Patient-Centered Primary Care Collaborative continue to pilot patient-centered medical home initiatives as a way to control health care costs and improve quality of care. This article reports the success of various models of patient-centered medical home initiatives in 10 countries, including the U.S.

Catalyst Center
February 2012
The current system of health care often does not cover, or provides inadequately, many services essential to the diagnosis and treatment of children and youth with autism spectrum disorders and other developmental disabilities (ASD/DD). These significant gaps in health services put children and youth with ASD/DD at risk for missed or delayed care; in addition, their families often experience significant financial hardship. The Patient Protection and Affordable Care Act (ACA) was designed to increase health coverage, improve benefits, and provide important new insurance protections for all Americans. Many of the law's provisions will impact children and youth, including those with ASD/DD.

The Catalyst Center has developed The Affordable Care Act and Children and Youth with Autism Spectrum Disorder and Other Developmental Disabilities, a new report for the Association of Maternal & Child Health Programs (AMCHP) that offers a brief description of selected provisions in the ACA that have implications for children and youth with ASD/DD. It also describes how state Title V maternal and child health (MCH) programs can maximize opportunities under the ACA to develop and strengthen systems of care for children and youth with ASD/DD.

Events2Are You Game for Some Learning Fun?
Catalyst Center
March 2012
Last month, the Catalyst Center announced the completion of its Public Insurance Programs and Children with Special Health Care Needs: A Tutorial on the Basics of Medicaid and the Children's Health Insurance Program (CHIP). This user-friendly overview of Medicaid and CHIP coverage for children and youth with special health care needs (CYSHCN), specially written with Title V maternal and child health (MCH) staff and family leaders in mind, is available on our website. If you haven't had a chance to read it, in whole or in part, please check it out. And, when you're done, please take a short User Survey; your feedback will help us improve our materials.

If you have completed the tutorial, we invite you to test your knowledge by playing a game of Medicaid/CHIP Jeopardy or challenging yourself with a Medicaid Tutorial Crossword. Feel free to download the tutorial, games, and game instructions and answer keys for personal use or for use at workshops and other informational events.

QuickTipsNews You Can Use from Our Partners  

MCH Library Offers Ready Access to MCH Statistics, Research, and Programs
MCH Library at Georgetown University
March 2012
The Maternal and Child Health (MCH) Library at Georgetown University has developed a set of resource briefs to help you quickly locate data sets, data tools, and statistics; literature and research; and programs to improve families' health and well-being. Whether your focus area is infant mortality, bullying, or adolescent pregnancy, the briefs will point you to the tools you need to answer specific statistical questions, learn about the latest research in the field, or find effective programs about any MCH topic. The MCH Library welcomes your comments and requests that you share this information with your colleagues via your website or e-news services.

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PastIssuesIn case you missed is the most popular news item from our last issue of the Week In Review

By Carey Goldberg
CommonHealth Reform and Reality Boston's NPR News Source
February 10, 2012
Two sections of the Affordable Care Act (ACA) address Accountable Care Organizations or ACOs. In particular, section 2706 specifies requirements for a Pediatric ACO Demonstration Project that is short on details about exactly what an ACO is. To answer this question, CommonHealth Reform and Reality has created a short (just over 5 minutes), laugh-out-loud video that explains ACOs. Watch the video or read the transcript.

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To view more articles from past issues of the Week In Review, visit the Catalyst Center website. If you have suggestions for news items related to coverage and financing of care for CYSHCN please email Week In Review editor and Catalyst Center Assistant Director Beth Dworetzky by 12 pm EST on Friday at


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The Catalyst Center is a national center dedicated to improving health care insurance and financing for Children and Youth with Special Health Care Needs (CYSHCN). For more information please visit us at or contact Meg Comeau, Program Director at


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The Catalyst Center is funded under grant #U41MC13618 from the
Maternal and Child Health Bureau, Health Resources and Services Administration
U.S. Department of Health and Human Services.