Grants and Demonstrations

The ACA provides funding opportunities to transform how health care is delivered, expand access to care and support healthcare workforce training.

Grant Activity

Guidance

8/30/13 CMS issued the third in a series of letters that provides states with guidance on designing and implementing care delivery and payment reforms that improve health, improve care, and reduce costs within Medicaid programs. The guidance, issued as a State Medicaid Director (SMD), SMDL#13-005, describes the methodological considerations that states may factor into any shared savings proposals, as well as technical guidance and a series of questions that CMS will expect states to answer as part of their proposals. Shared savings programs are authorized by ACA §3021 to help facilitate coordination among providers to improve the quality of care for Medicare beneficiaries, organizations were able to lower costs and improve health outcomes when compared to fee-for-service Medicare. Many states are interested in testing shared savings methodologies in the Medicaid program as a means to promote higher quality at an overall lower cost.

The previous State Medicaid Director (SMD) letters, SMD #12-001 and SMD #12-002, describe the policy considerations for creating "Integrated Care Models" (ICMs), which could include (but are not limited to) medical/health homes, Accountable Care Organizations (ACOs), ACO-like models, and other arrangements that emphasize person-centered, continuous, coordinated, and comprehensive care. The SMD letters describe the framework for ICMs and pathways that states may use to implement ICMs in the Medicaid state plan or, as needed, through appropriate program waivers and demonstrations.  

SMDL#13-005 focuses on reimbursement methodologies that can be adopted in the context of ICMs to incentivize improved quality and outcomes and reduce costs by sharing program savings with high performing providers

ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve to helps ensure that patients, especially the chronically ill, get appropriate care, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. 

Information about current ACO programs can be found at: http://innovation.cms.gov/initiatives/ACO/

8/28/13 HHS/CMS issued the final rule "Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, and Eligibility Appeals." The goal of the final rule is to ensure access to affordable health insurance for consumers and to safeguard federal funds through program integrity activities. The final rule finalizes policies from the June 19, 2013 proposed rule "Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards," published on June 19, 2013. According to the HHS/CMS, the final rule addresses the provisions of the June proposed regulations that need to be effective for the beginning of open enrollment on the Health Insurance Exchanges on October 1, 2013; other provisions will be finalized at a later date. The final rule also finalizes eligibility and Small Business Health Options Program (SHOP) appeals provisions from the January 22, 2013 proposed rule, "Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Procedures for Medicaid and Exchange Eligibility Appeals."

The final rule establishes standards for eligibility appeals, verification of eligibility for minimum essential coverage, and treatment of incomplete applications. It also establishes additional consumer protections regarding privacy and security; clarifies the role of agents, brokers, and QHP issuer application assisters who provide services and supports to assist consumers with obtaining health insurance coverage through an Exchange; provides for the handling of consumer cases and complaints; and establishes non-discrimination standards for methods of premium payment. The final rule also describes provisions regarding a State's operation of the Exchange and SHOP.

The ACA established Affordable Health Insurance Exchanges (§1311(b)) to provide individuals and small business employees with access to health insurance coverage beginning January 1, 2014, where low and moderate income Americans will be eligible for premium tax credits (§1401, §1411) to make purchasing a health plan more affordable by reducing out-of-pocket premium costs. §1311(b)(1)(B) requires that SHOP assist qualified small employers in facilitating the enrollment of their employees in qualified health programs (QHPs) offered in the small group market. QHPs are health plans that have been certified by an Exchange, provide essential health benefits (§1301) and follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts). 

Although a part of the final rule focuses on program integrity issues regarding QHP issuers offering coverage in the Federally-facilitated Exchange, the final rule also addresses other provisions designed to protect consumers and maintain continued and efficient operation of the Exchange, while also granting flexibility to states. Under the final rule, QHP issuers are required to accept a variety of payment methods in order to ensure that consumers are given several methods to make payments of their monthly premiums. Employers seeking to contest Exchange determinations regarding whether the employer provides minimum essential coverage (MEC) that meets both minimum value and affordability standards will be able to do so through a separate HHS-Secretary directed process. State-based Exchanges will have the flexibility to establish a state-based appeals process for employer appeals, and HHS will provide the process if the state does not opt to do so or does not operate a State-based Exchange. HHS also provides flexibility by allowing states to run a state-based Small Business Health Options Program (SHOP) while the federal government manages the individual market in the Federally-facilitated Exchange.