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May 1st Legislative Update

by Cathy Carver and Lynn Wickwire

Federal

May 1 is the deadline for insurers to apply to offer qualified health plans in state-run exchanges, and the submissions will signal the vigor of competition as the marketplaces begin enrolling members in October. Late Monday, the CMS said it would extend the deadline for insurers in states with federally run exchanges to submit qualified health plans from today to Friday. Large carriers have indicated that they will be conservative in choosing where to join the fray. During a conference call Tuesday to discuss first-quarter earnings, Aetna president and CEO Mark Bertolini said the carrier plans on selling insurance in 14 exchanges

For the approximately 10 percent to 15 percent of Americans who either do not have health insurance or purchase their coverage on the individual market - about 30 million people, the law creates exchanges, or online marketplaces, where, beginning in October, eligible individuals and small businesses will be able to purchase coverage, with some qualifying for federal subsidies.

If states do not set up an exchange, the federal market will do it for them. Seventeen states and the District of Columbia have decided to set up their own exchanges. Another seven states are partnering with the federal government to set up the marketplaces, and 26 have defaulted to the federal government to do all the work.

There's a lot of concern about how much it will cost to buy health insurance on the new exchanges coming online later this year. Some states are predicting double digit increases in premiums.

A new report proposes system-wide reforms to Medicare, Medicaid, and private insurance markets and exchanges that could save the United States $300 billion dollars in the coming decade and $1 trillion over the next 20 years, as well as improve care quality and patient health. The report focuses on changes that will shift payment from the current fee-for-service paradigm to one that is more person-centered.

Commonwealth of Massachusetts

The Health Policy Commission (HPC) and its four committees continue to actively implement Chapter 224, health care cost control legislation. One important item is that whenever there is going to be any change in operating structure or affiliations, that the HPC be notified at least 60 days prior to the implementation of the proposed change. This requirement is included in the procedure for cost and market impact reviews (CMIR) established by the HPC.

The Commission also is developing a "registration program for provider organizations" This requires a 2 year renewable term and must be filed by any provider organization which is defined as:

- any provider or provider organization that is a risk-bearing organization (as defined by DOI), and

- any provider or provider organization with a patient panel greater than 15,000 and which represents providers who collectively receive $25,000,000 or more in annual net patient service revenue from carriers or third-party administrators.

The regulations will be developed this year in coordination with other state agencies to avoid duplication.

The HPC also is developing standards for certification of patient-centered medical homes (PCMH). These will be done in conjunction with other state agencies to minimize duplicative efforts and to promote transparency. Both the PCMH and provider organization registrations are expected to be in place by January 1, 2014.

Catherine Carver, MS, ANP, CDE
Vice President, Advocacy and Planning

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Page last updated: October 20, 2014