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AFFORDABLE CARE ACT
MASSACHUSETTS IMPLEMENTATION UPDATE

February 18, 2014
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These Updates, published by the Executive Office of Health and Human Services (EOHHS) in consultation with the other state agencies involved in ACA implementation, will bring you news related to the implementation of provisions of the ACA here in Massachusetts.

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 Announcements

 

The Patient Centered Outcomes Research Institute (PCORI), §6301, announced eight grant opportunities on February 5, 2014. Created under ACA §6301, PCORI is an independent nonprofit organization, tasked with conducting patient-centered outcomes research and studies.

For more information about PCORI, visit PCORI

For more information about PCORI funding opportunities, visit:

www.pcori.org/funding-opportunities.


Pragmatic Clinical Studies and Large Simple Trials to Evaluate Patient Centered Outcomes: Funding is available to conduct clinical trials, large simple trials, or large-scale observational studies that compare two or more alternatives for addressing prevention, diagnosis, treatment, or management of a disease or symptom; improving health care system-level approaches to managing care; or for eliminating healthcare disparities. Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $90,000,000 in total for 6 to 9 awards available.

Letters of Intent are due March 7, 2014.

Applications are due May 6, 2014.


The announcement for this opportunity can be found at: http://www.pcori.org/funding-opportunities/funding-announcements/pragmatic-clinical-studies-and-large-simple-trials-to-evaluate-patient-centered-outcomes/


The Effectiveness of Transitional Care: Funding is available to conduct research that will determine which transitional care service clusters are most effective in improving patient-centered outcomes, while optimizing re-admission rates in different at-risk subpopulations and in different healthcare contexts. Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $15,000,000 is available for one award.

Letters of Intent are due March 7, 2014.

Applications are due May 6, 2014.


The announcement for this opportunity can be found at: http://www.pcori.org/funding-opportunities/funding-announcements/the-effectiveness-of-transitional-care/


Obesity Treatment Options Set in Primary Care for Underserved Populations: Funding is available to create two pragmatic, randomized, multi-site clinical trials that focus on improving obesity treatment outcomes in primary care settings for racial/ethnic minority populations. Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $20,000,000 in total for 2 awards available.

Letters of Intent are due March 7, 2014.

Applications are due May 6, 2014.


The announcement for this opportunity can be found at:

http://www.pcori.org/funding-opportunities/funding-announcements/assessment-of-prevention-diagnosis-and-treatment-options-spring-2014-cycle/


Assessment of Prevention, Diagnosis, and Treatment Options: Funding is available to conduct research that will provide information about health care outcomes to help caregivers, clinicians and policy makers make decisions regarding prevention, screening, diagnosis, monitoring, or treatment of patients. Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $32,000,000 is available for one award.

Letters of Intent are due March 7, 2014.

Applications are due May 6, 2014.


An announcement for this opportunity can be found at:

http://www.pcori.org/funding-opportunities/funding-announcements/assessment-of-prevention-diagnosis-and-treatment-options-spring-2014-cycle/


Improving Healthcare Systems: Funding is available to study the comparative effectiveness of alternate features of healthcare systems designed to optimize the quality, outcomes, and/or efficiency of care for the patients they serve. Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $16,000,000 is available for one award.

Letters of Intent are due March 7, 2014. 

Applications are due May 6, 2014.


An announcement for this opportunity can be found at:

http://www.pcori.org/funding-opportunities/funding-announcements/improving-healthcare-systems-spring-2014-cycle/


Communication and Dissemination Research: Funding is available for projects that address critical knowledge gaps in the communication and dissemination process of research results to patients, their caregivers, and clinicians. Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $8,000,000 in total for up to 5 awards available.

Letters of Intent are due March 7, 2014.

Applications are due May 6, 2014.


An announcement for this opportunity can be found at:

http://www.pcori.org/funding-opportunities/funding-announcements/communication-and-dissemination-research-spring-2014-cycle/


Addressing Disparities: Funding is available to conduct comparative clinical effectiveness research studies that evaluate and compare new and alternative interventions with usual care to overcome barriers or eliminate disparities in health care that may disproportionately affect the health outcomes of specific groups of patients.Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $8,000,000 in total for 5 awards available.

Letters of Intent are due March 7, 2014.

Applications are due May 6, 2014.


An announcement for this opportunity can be found at:

http://www.pcori.org/funding-opportunities/funding-announcements/addressing-disparities-spring-2014-cycle/
 

Improving Methods for Conducting Patient-Centered Outcomes Research: Funding is available to address gaps in research relevant to conducting Patient-Centered Outcomes Research (PCOR). These findings will be used in future PCORI Methodology Reports that are used to help clinicians and patients make informed care decisions. Eligible applicants include: private or public research organizations; nonprofit or for-profit organizations; university or college hospitals or healthcare systems; or local, state, or federal government agencies. $17,000,000 is available for one award.

Letters of Intent are due March 7, 2014.

Applications are due May 6, 2014.


An announcement for this opportunity can be found at:

http://www.pcori.org/funding-opportunities/funding-announcements/improving-methods-for-conducting-patient-centered-outcomes-research-spring-2014-cycle/

   

 

Grant Activity
 

For information about ACA grants awarded to and grant proposals submitted by the Commonwealth, visit the Grants page of the Massachusetts National Health Care Reform website at: http://www.mass.gov/eohhs/gov/commissions-and-initiatives/healthcare-reform/national-health-care-reform-plan/grants-and-demonstrations.html

 

Guidance

 

2/10/14 IRS/Treasury issued final regulations called "Shared Responsibility for Employers Regarding Health Coverage" under Section 4980H which was added to the IRS Code by ACA §1513. The ACA establishes that certain employers must offer health coverage to their full-time employees or a shared responsibility payment may apply. For 2015 and after, "applicable large employers," those employers employing at least a certain number of employees (employers with 50 or more full-time employees*) must offer affordable health coverage that provides a minimum level of coverage (§1501) to their full-time employees (and their dependents), or the employer may be subject to an employer shared responsibility payment if at least one of its full-time employees receives a premium tax credit (§1401, §1411) for purchasing individual coverage on one of the Affordable Insurance Exchanges (Marketplaces).

 

The final rules amend the proposed regulations (issued in December 2012) in response to input the agency received. Broadly, the changes in the final rules phase-in the shared responsibility payment requirements for larger employers. Key components of the final rules provide, 1) a phase in in the percentage of full-time workers that certain large employers (large employers with 100 or more employees) are required to offer coverage: from 70% in 2015, to 95% in 2016 (and beyond). In 2015, employers in this category that do not meet these standards will make an employer responsibility payment for 2015 and 2) transition relief for companies with 50-99 employees that do not yet provide employer-sponsored health coverage that is affordable and provides minimum value to their full-time workers who will be required to report on their workers and coverage in 2015, but have until 2016 before any employer responsibility payments could apply.

 

The ACA provides that small businesses (companies with fewer than 50 employees) are not required to provide health care coverage in 2015 (or in any year). The final rules do not change this. According to the IRS, 96% of all employers fall into this category.

 

Beginning October 1, 2013, qualified individuals and qualified employees could purchase private health insurance coverage through Exchanges (Marketplaces) for January 1, 2014 effective dates. 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. Furthermore, an Exchange makes an advance determination of tax credit eligibility for individuals who enroll in a qualified health plan (QHP) through the Exchange and pursue financial assistance (§1401, 1411, and 1412). QHPs are health plans that have been certified by an Exchange, provide essential health benefits (EHB, §1301) and follow established limits on cost-sharing (such as reduced deductibles, copayments, and out-of-pocket maximum amounts).

 

According to the IRS, final regulations will also be issued that will simplify the annual information reporting requirements applicable to insurers, self-insuring employers and certain other providers of minimum essential coverage under ACA §1502 and the annual information reporting requirements applicable to large employers relating to the health insurance that the employer offers (or does not offer) to its full-time employees (§1514).

 

*Under the ACA, 50 full-time employees or a combination of full-time and part-time employees is equivalent to 50 full-time employees. A full-time employee is an individual employed on average at least 30 hours of service per week. An employer that meets the 50 full-time employee threshold is referred to as an applicable large employer.

 

Read the final rule (which was published in the Federal Register on February 12, 2014) at: http://www.gpo.gov/fdsys/pkg/FR-2014-02-12/pdf/2014-03082.pdf

Read the IRS fact sheet at:

http://www.treasury.gov/press-center/press-releases/Documents/Fact%20Sheet%20021014.pdf

 

2/10/14 HHS/CMS issued a notice under the Paperwork Reduction Act of 1995 (PRA) seeking comments on revised information collection activities related to the initial plan data collection to support Qualified Health Plan (QHP) certification and other financial management and exchange operations.

 

According to HHS/CMS, the information collection will ensure that QHPs meet certain minimum certification standards, such as those pertaining to essential health benefits and actuarial value.

 

In order to meet those standards, the Exchange is responsible for collecting data and validating that QHPs meet these minimum requirements as described in the Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers Final Rule). In addition to data collection for the certification of QHPs,issuers, group health plans, third party administrators, and plan offerings outside of the Exchanges must adhere to the reporting requirements in the reinsurance and risk adjustment programs outlined in the Standards Related to Reinsurance, Risk Corridors and Risk Adjustment Final Rule.

 

Beginning October 1, 2013, qualified individuals and qualified employees could purchase private health insurance coverage through Exchanges (Marketplaces) for January 1, 2014 effective dates. 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. Furthermore, an Exchange makes an advance determination of tax credit eligibility for individuals who enroll in a qualified health plan (QHP) through the Exchange and pursue financial assistance (§1401, 1411, and 1412). QHPs are health plans that have been certified by an Exchange, provide essential health benefits (EHB, §1301) and follow established limits on cost-sharing (such as reduced deductibles, copayments, and out-of-pocket maximum amounts).

 

Comments are due March 12, 2014.

 

Read the notice at: http://www.gpo.gov/fdsys/pkg/FR-2014-02-10/pdf/2014-02787.pdf

 

2/4/14 The Office of Personnel Management (OPM) released its 2015 Multi-State Plan (MSP) Program Issuer Call Letter. The letter states that, in the program's second year, OPM intends to offer multistate plan coverage in at least five additional states and to add one or more insurers or groups of insurers to the MSP program. According to the letter, in 2015, MSP insurers are expected to offer both self- and family-coverage at the gold and silver level.

 

The MSP Program, authorized under ACA §1334, requires OPM, which administers the Federal Employees Health Benefits Program (FEHBP), to contract with at least two MSPs on each of the Affordable Insurance Exchanges. The MSP Program is intended to promote competition in the insurance marketplace and help ensure individuals and small employers have higher quality, affordable health insurance plans from which to choose beginning in 2014. An MSP program issuer may phase in the States in which it offers coverage over four years, but it must offer MSPs on Exchanges in all States and the District of Columbia by the fourth year in which the MSP program issuer participates in the MSP program. Health insurance issuers who wish to offer MSPs must complete an application. Although the MSP program is a federal program it will offer products through the state-level exchanges. In addition to compliance with the ACA's requirements that apply to all qualified health plans (QHPs), MSP's must also comply with applicable FEHBP requirements and be licensed by the states in which they do business. Under the ACA, OPM will negotiate a contract with each multi-state QHP in order for that plan to be certified for participation in that state's Exchange. 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).

 

In the first year of the program, OPM has certified more than 150 MSP options in 30 states (including Massachusetts) and the District of Columbia. OPM also certified MSP options for the Small Business Health Options Program (SHOP) in four states and the District of Columbia.

 

The 2015 application for insurers will be available by early 2014.

 

Read the 2015 call letter at:

http://www.opm.gov/media/4517978/2014-002_dms_.pdf

Learn more about the MSP program at:

http://www.opm.gov/healthcare-insurance/multi-state-plan-program/

Read the MSP program final rule (which was published the in Federal Register on March 11, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-03-11/pdf/2013-04954.pdf

2/4/14 CMS released a draft of the 2015 Letter to Issuers in the Federal-Facilitated Marketplace (FFM).  The Letter provides health plan issuers seeking to offer Qualified Health Plans (QHPs) (including stand-alone dental plans) in the FFM and/or Federally-facilitated Small Business Health Options Program (FF- SHOP) Marketplace with the fundamental conditions for participation in 2015.

 

The letter contains operational and technical CMS guidance for issuers about the QHP certification process. CMS outlines key dates, timeframes, and proposes enhanced standards for network adequacy and patient safety standards for 2015 QHP issuers.  

 

The ACA established Affordable Insurance Exchanges (§1311(b)) to provide individuals and small business employees with access to health insurance coverage beginning in 2014, where low and moderate income Americans may 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 ("EHB", §1301) and follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts). If states choose not to run either a State-Based Exchange or a State-Federal Partnership Exchange, HHS will operate a Federally-facilitated Exchange, FFM (§1321).

 

Comments are due February 25, 2014.

 

Read the Annual Issuer Letter at: www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/draft-issuer-letter-2-4-2014.pdf

 

Prior guidance can be found at: http://www.hhs.gov/healthcare/index.html

News 

2/11/2014 The CMS Innovation Center issued a Request for Information (RFI) to obtain feedback on Specialty Practitioner Payment Model Opportunities. CMS is considering policy options for the development of innovative payment and service delivery models that will focus on specific diseases, patient populations, and specialty practitioner services in the outpatient setting.

 

In order to develop these models (and test whether they can improve health care outcomes and reduce costs) CMS is seeking input in the RFI from stakeholders on two potential models 1) procedural episode- based payment models and 2) complex and chronic disease management episode-based payment models.

The CMS Innovation Center, authorized under ACA §3021, is tasked with testing new health care payment and service delivery models that enhance the quality of Medicaid, Medicare and the Children's Health Insurance Program while also lowering program costs

Responses are due March 13, 2014.

 

For more information or to submit your comments please visit:

http://innovation.cms.gov/initiatives/Specialty-Practitioner/

 

2/11/14 The U.S. Preventive Services Task Force (USPSTF) issued a draft recommendation statement on screening for hepatitis B virus infection (HBV) in nonpregnant adolescents and adults. The USPSTF recommends screening for HBV infection in individuals who are at high risk for infection. The USPSTF assigned a "B" rating to the recommendation, indicating that the Task Force recommends the service.

 

According to the USPSTF, although the vaccination rate for hepatitis B among people born in the United States is high (and the most effective way to prevent infection is with vaccination), there are still approximately 1 million people in the U.S. chronically infected with HBV infection. Furthermore, among individuals with chronic HBV infection, 15% - 25% die from liver disease or liver cancer.

 

The USPSTF's evidence review found that high risk factors for developing HBV infection included: individuals who were born in other countries with a high prevalence of HPV infection, U.S. born individuals who were not vaccinated, individuals who are HIV-positive, injection drug users, men who have sex with men, and patients with a weakened immune system.

 

However, the prevalence of HBV infection is generally low in the U.S. population, and most infected individuals do not develop complications. Therefore, screening is not recommended in the general population for individuals who area symptomatic.

 

The USPSTF is an independent panel of non-federal government experts that conduct reviews of scientific evidence of preventive health care services. The USPSTF then develops and publishes recommendations for primary care clinicians and health systems in the form of recommendation statements. As part of their recommendations process, the USPSTF will assign definitions to the services they review based on the certainty that a patient will receive a substantial benefit from receiving the benefit. Services that are graded "A" and "B" are highly recommended and the USPSTF believes there is a high certainty that patient will receive a substantial or moderate benefit. 

 

Under ACA §1001, all of the recommended services receiving grades of "A" or "B" must be provided without cost-sharing when delivered by an in-network health insurance provider in the plan years (or, in the individual market, policy years) that begin on or after September 23, 2010. If the recommendation is finalized with the "B" rating, then the HBV screenings for high-risk populations will be required to be covered without cost-sharing under the ACA.

 

Comments on the draft are due March 10, 2014 and can be submitted at: http://www.uspreventiveservicestaskforce.org/draftrep.htm

 

Read the draft recommendation statement at: http://www.uspreventiveservicestaskforce.org/draftrec2.htm

Learn more about preventive services covered under the ACA at: HHS.Gov 

Learn more about the USPSTF at: http://www.uspreventiveservicestaskforce.org/

  

Commonwealth of MA News

 

State Plan Amendments for Massachusetts Alternative Benefit Plans: Public Comment Period

The Executive Office of Health and Human Services (EOHHS) plans to submit to the Centers for Medicare and Medicaid Services (CMS) by March 31, 2014 two State Plan Amendments (SPAs) authorizing MassHealth's two Alternative Benefit Plans (ABPs) under the Affordable Care Act. EOHHS will accept comments on the proposal contained in the summary linked below through 5:00 pm on February 21, 2014.

 

A summary of the proposed SPAs and information about how to submit comments are available at: http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/alternate-benefit-plans-public-notice.pdf

 

Upcoming Events

 

Integrating Medicare and Medicaid for Dual Eligible Individuals (also known as One Care) Open Meetings

  

Friday, February 21, 2014, 1:00-3:00 PM
State Transportation Building, Conference Room 1-3
10 Park Plaza
Boston, MA

 

We welcome attendance from all stakeholders and members of the public with an interest in One Care. Reasonable accommodations will be made for participants who need assistance. Please send your request for accommodations to Donna Kymalainen at Donna.Kymalainen@state.ma.us.

 

Integrating Medicare and Medicaid for Dual Eligible Individuals (also known as One Care) Implementation Council Meetings

  

Friday, February 28, 2014
11:00 AM-1:00PM
1 Ashburton Place, 21st Floor
Boston, MA


Friday, March 28, 2014

1:00 PM -3:00 PM

1 Ashburton Place, 21st Floor

Boston, MA

 

MBTA and driving directions to 1 Ashburton Place are located here: www.mass.gov/anf

 

A meeting agenda and any meeting material will be distributed prior to the meeting.

 

Meetings of the Implementation Council are open to stakeholders and members of the public with an interest in One Care. Reasonable accommodations are available upon request. Please contact Donna Kymalainen at Donna.Kymalainen@umassmed.edu to request accommodations. 

Bookmark the Massachusetts National Health Care Reform website at: 

National Health Care Reform to read updates on ACA implementation in Massachusetts.

 

Remember to check the Mass.Gov website at: Dual Eligibles for information on the "Integrating Medicare and Medicaid for Dual Eligible Individuals" initiative.