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

On September 18, 2013, DPH submitted a "Treatment Options for Uncontrolled Asthma" grant to the Patient-Centered Outcomes Research Institute (PCORI) under ACA §6301. Funding is available for comparative effectiveness research (CER) that focuses on reducing adverse outcomes due to poorly controlled asthma in African-American or Black and Hispanic or Latino individuals and other specific minority populations disproportionately affected by uncontrolled asthma. Created under ACA §6301, PCORI is an independent nonprofit organization, tasked with conducting patient-centered outcomes research and studies.

The DPH proposed study aims to improve asthma outcomes and quality of life for African-American or Black and Hispanic or Latino older adults with asthma by adding a team-based intervention that includes a home-visiting community health worker, visiting nurse and pharmacist to their primary care team for asthma management for older adults. The study will answer the question of whether this approach improves patient self- management and adherence to guidelines such as directed care when compared to usual care, with resultant reduction in emergent healthcare utilization and improvement in asthma control and quality of life.

To facilitate the study, DPH will work with the following partners: Brigham and Women's Hospital - Partners Asthma Center, Tufts Medical Center - Asthma Center, Boston Public Health Commission, Greater Lawrence Family Health Center, and Northeastern University Urban Health Institute. Additional partners will include Massachusetts Executive Office of Elder Affairs, Massachusetts Association of Pharmacists, Massachusetts Association of Community Health Workers, Visiting Nurse Associations, and Massachusetts Association of Councils on Aging.

Read the grant abstract at: http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/grants/130918-sec-6301-treatment-options-uncontrolled-asthma.pdf

Guidance

9/25/13 DOL issued a final rule called, "Regulations Implementing the Byrd

Amendments to the Black Lung Benefits Act: Determining Coal Miners' and Survivors' Entitlement to Benefits." The final rule implements amendments to the Black Lung Benefits Act (BLBA) made by ACA §1556.The Black Lung Benefits Act provides benefits, in cooperation with the states, to coal miners who are totally disabled due to pneumoconiosis (black lung disease) and to the surviving dependents of miners whose death was due to such disease; and to ensure that in the future adequate benefits are provided to coal miners and their dependents in the event of their death or total disability due to pneumoconiosis. The amendments reinstate two provisions regarding coal miners' and survivors' entitlement to benefits that had been previously repealed from the BLBA.

The first amendment provides a presumption of total disability or death caused by pneumoconiosis for coal miners who worked for at least 15 years in underground mining and who suffer or suffered from a totally disabling respiratory impairment. The second amendment provides automatic entitlement for eligible survivors of miners who were themselves entitled to receive benefits as the result of a lifetime claim.

The final rule addresses both new methods of establishing entitlement- the automatic entitlement of certain survivors and the 15-year presumption as it applies to both miners' and their survivors' claims. From 1982 until the ACA was enacted, survivors of a coal miner who was totally disabled due to pneumoconiosis had to prove that pneumoconiosis had caused the miner's death to be entitled to benefits. Since the ACA was passed several U.S. Appeals courts have upheld the ACA amendment that automatically continues benefits to a miner's eligible survivors if the miner was entitled to benefits on a claim filed prior to death and also upheld the reinstated 15-year presumption.

For more information on the BLBA visit: http://www.dol.gov/compliance/laws/comp-blba.htm#applicable_laws

Read the rule at: http://www.gpo.gov/fdsys/pkg/FR-2013-09-25/pdf/2013-22874.pdf

9/20/13 HHS/CMS issued a proposed rule called "Basic Health Program: State Administration of Basic Health Programs; Eligibility and Enrollment in Standard Health Plans; Essential Health Benefits in Standard Health Plans; Performance Standards for Basic Health Programs; Premium and Cost Sharing for Basic Health Programs; Federal Funding Process; Trust Fund and Financial Integrity." The proposed rule implements ACA §1331 which establishes standards for the Basic Health Program (BHP) which provides states the option to establish a health benefits coverage program for low-income individuals who would otherwise be eligible to purchase coverage through the Health Insurance Exchange (Marketplace).

The proposed rule sets forth a framework for BHP eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, state administration and federal oversight. Citizens or lawfully present non-citizens who do not qualify for Medicaid, the Children's Health Insurance Program (CHIP) or other minimum essential coverage and have income between 133% FPL and 200% FPL are eligible for the BHP.

Beginning January 1, 2014, ACA §2001 requires states to expand their Medicaid programs to individuals under 65 years of age with incomes at or below 133% FPL. (However, on June 28, 2012 the Supreme Court ruled that the Medicaid expansion was optional for states and that the HHS Secretary could not withdraw federal funding from non-expanding states' pre-existing Medicaid programs). The ACA established Affordable 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) also requires that the Small Business Health Options Program (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).

Beginning January 1, 2015, as authorized by §1331 and this proposed rule, states will have an additional option to establish a BHP for certain low-income individuals who would otherwise be eligible to obtain coverage through the Exchange.

According to the proposed rule, BHP benefits will include at least the ten essential health benefits specified in §1301. BHP monthly premiums and cost sharing cannot exceed what an eligible individual would have paid if the eligible individual were to receive coverage from a QHP through the Exchange. A state that operates a BHP will receive federal funding equal to 95% of the amount of the premium tax credits and the cost sharing reductions that would have otherwise been provided to (or on behalf of) eligible individuals if these individuals enrolled in QHPs through the Exchange.

Comments are due November 25, 2013.

Read the proposed rule (which was published in the Federal Register on September 25, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-09-25/pdf/2013-23292.pdf

9/18/13 HHS issued a proposed rule called "Medicare Program; Prospective Payment System for Federally Qualified Health Centers (FQHCs); Changes to Contracting Policies for Rural Health Clinics; and Changes to Clinical Laboratory Improvement Amendments of 1988 Enforcement Actions for Proficiency Testing Referral." The proposed rule implements ACA §10501.

FQHCs provide comprehensive primary and preventive health services and are generally required to treat all patients regardless of their ability to pay, offering services on a sliding fee scale to people with incomes below 200% FPL. According to HHS, most FQHCs are funded by federal grants. Medicare currently pays FQHCs one comprehensive rate for the professional component of certain primary and preventive health services furnished to the same beneficiary on the same day.

The proposed rule amends the current Medicare FQHC payment policy by requiring the establishment of a new payment system, effective with cost reporting periods beginning on or after October 1, 2014. The proposed rule establishes a methodology and payment rates for a prospective payment system (PPS) for FQHC services under Medicare Part B. Broadly, the Medicare FQHC PPS takes into account the type, intensity, and duration of FQHC services and allows other adjustments such as geographic adjustments.

The proposed rule also establishes a policy which would allow rural health clinics (RHCs) to contract with nonphysician practitioners when statutory requirements for employment of nurse practitioners and physician assistants are met. Additionally, the proposed rule makes changes to the Clinical Laboratory Improvement Amendments regulations regarding enforcement actions for proficiency testing referral.

Comments are due November 18, 2013.

Read the proposed rule (which was published in the Federal Register on September 23, 2013) at:

http://www.gpo.gov/fdsys/pkg/FR-2013-09-23/pdf/2013-22821.pdf

9/24/13 The U.S. Preventive Services Task Force (USPSTF) issued a final recommendation statement and final evidence report on medications for risk reduction of primary breast cancer in women. The Task Force recommends that clinicians engage in shared decision-making with women at increased risk of breast cancer regarding medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications such as tamoxifen or raloxifene. Tamoxifen and raloxifene are selective estrogen receptor modulators, medications that block the effects of estrogen in the breast tissue and have been shown to reduce the risk of hormone receptor (HR) positive breast cancer, a type of cancer that receives signals from estrogen in a way that could promote the cancer cell's growth. The final recommendation statement applies to asymptomatic women older than age 35 who have not previously been diagnosed with breast cancer, or who have a history of blood clots, stroke, or "mini-strokes".