States with Republican governors kept up the pressure last week on Washington to give the states greater control over health care under the Patient Protection and Affordable Care Act (PPACA). Twenty-one Republican governors sent a letter to Health and Human Services (HHS) Secretary Kathleen Sebelius asking for greater authority over some provisions of health reform, including the ability to define "essential" health benefits and set minimum criteria for participating in insurance exchanges. They threatened not to run their own state-based exchanges if HHS does not act on their requests. Sebelius quickly responded with her own letter in which she reviewed the various options states have to reduce costs in their Medicaid programs, and she indicated she is continuing to review what authority she may have to "waive the maintenance of effort under current law." Senate bills have already been introduced to address the role of the states in health care reform, which is sure to keep the issue on the front burner. Visit Easy To Insure ME for more infoFederalThe House Committee on Ways & Means held a hearing last week on "The Health Care Law's Impact on Medicare and Its Beneficiaries," featuring testimony from CMS Administrator Donald Berwick, M.D., and CMS Chief Actuary Richard Foster. Berwick testified that the PPACA has had a positive impact on Medicare beneficiaries, noting that beneficiaries now have first-dollar coverage of key preventive benefits, additional assistance with prescription drug costs, and an annual wellness visit with the physician of their choice. In response to concerns noted by several committee members about the impact of funding cuts on Medicare Advantage, Berwick indicated that Medicare Advantage enrollment increased by 6 percent from 2010 to 2011. He suggested that the program is healthy and offers robust choices. Foster's testimony reiterated his prior projection that the PPACA will cause Medicare Advantage enrollment to decline by about 50 percent by 2017 -- from a projected 14.5 million under the pre-PPACA law to 7.3 million under the new law. His testimony further explained that Medicare Advantage enrollees will experience "a large increase in out-of-pocket costs" and "less generous benefit packages" because PPACA will reduce rebates to Medicare Advantage plans, with the reduction in rebates reaching $1,500 per beneficiary by 2019.The Administration last week issued favorable guidance with respect to student health coverage that will result in little disruption, if any, to this business until at least the 2012-2013 academic year. This guidance was announced in a Notice of Proposed Rule Making (rather than as an interim final regulation), which fortunately means that the rule is not effective immediately as has been the case with most regulations relating to PPACA reforms. The proposed student health rule would create a special class of individual coverage for student health pursuant to a set of factors, e.g., written contract between school and insurer, coverage only for students and dependents, health status may not be used as a condition of eligibility. As Aetna has advocated, the impact would be delayed, as the rule (whenever finalized) would not be effective until policy years beginning on or after January 2012. Until then, student health is not subject to PPACA reforms. And, when effective, student health would be excepted from the current guaranteed issue and renewability provisions of PPACA. While it will be unclear for a while whether and how student health will be subject to the medical loss ratio (MLR) provisions of PPACA, we are encouraged by the fact that the proposed rule invites comments on whether student health should receive some sort of special accommodation (akin to the special rule for limited benefit plans) with respect to MLR, owing to the unique characteristics of the student health market.StatesARIZONA: The industry-supported exchange bill was introduced last week under the sponsorship of the House Health Committee Chairman and the respective chairmen of the House and Senate Banking and Insurance Committees. The bill provides for a market-based mechanism; governance by a board with insurer representation; no dual regulation; and a conditional repeal provision. The first hearing will be held this week. In other news, Governor Jan Brewer appointed Don Hughes, former AHIP retained counsel, as Special Advisor for Health Care Innovation. Hughes will help direct state efforts to improve the cost-effectiveness and accessibility of health care. He will engage in strategic planning with a focus encompassing both public health care and Arizona's large private health insurance industry.ONNECTICUT: A jointly held public hearing of the Public Health and Insurance and Real Estate Committees was scheduled for this week on two new health care bills. The first bill would establish the SustiNet Plan Authority, a quasi-public agency empowered to implement a public health care option. The SustiNet Plan is a health insurance program that consists of coordinated individual health insurance plans that provide health insurance products to state employees, Medicaid enrollees, HUSKY Plan, Part A and Part B enrollees, HUSKY Plus enrollees, municipalities, municipal-related employers, nonprofit employers, small employers, other employers, and individuals in Connecticut. The Authority is authorized, but not required, to begin offering SustiNet coverage to employees and retirees of non-state public employers, municipal-related employers, small employers, and nonprofit employers after January 1, 2012. Beginning on January 1, 2014, SustiNet will offer coverage to individuals and employers. Among other things, the bill directs the Authority to implement primary care case management and patient-centered medical homes for all SustiNet Plan members, establish a pay-for-performance system, and establish procedures to prevent adverse selection.The Committees also will hear testimony on a bill to establish the Connecticut Health Insurance Exchange pursuant to PPACA. The exchange would be a quasi-public agency offering qualified health plans to individuals and qualified employers by January 1, 2014. The bill would establish a 13-member board of directors to manage the exchange. The exchange would have the authority to review the rate of premium growth within and outside the exchange in order to develop recommendations on whether to continue limiting qualified employer status to small employers. It also would have the authority to charge assessments or user fees to health carriers to generate funding necessary to support the operations of the exchange. The bill directs the exchange board to report to the legislature by January 1, 2012 on whether to establish two separate exchanges, one for the individual market and one for the small employer market, or to establish a single exchange; whether to merge the individual and small employer health insurance markets; whether to revise the definition of "small employer" from not more than 50 employees to not more than 100; and whether to allow large employers to participate in the exchange beginning in 2017.Aetna will submit comments on both bills through the Connecticut Association of Health Plans.IDAHO: Draft legislation is circulating that would prohibit insurance companies and managed care organizations from refusing to contract with qualified providers solely because the provider: is not a member of a group, network or any other organization of providers contracting with the insurance company; or does not offer all of the services obtained through the group, network or organization of providers contracting with the insurance company. However, the provider may be required to comply with the practice standards and quality requirements of the contract specific to the services contracted. The bill generally is intended to impact insurers and managed care organizations. It does not contain an exclusion or exception for HIPAA-excepted benefits. As yet, the bill has not found a sponsor and has not been "introduced." While there remains a possibility that the bill could be introduced before the deadline for committee bill introductions, it is considered unlikely.MINNESOTA: When the legislature convened the first half of its 2011-2012 biennium last month, Republicans controlled both legislative chambers for the first time since 1972. And, Republican lawmakers wasted little time introducing bills to repeal measures passed by the 2010 legislature to fund state medical assistance, general assistance medical care, and MinnesotaCare. In his first official act as Governor, Mark Dayton signed an executive order implementing early Medicaid expansion (to 133 percent of the federal poverty level) for Minnesota, which is expected to make 95,000 more state residents eligible. Minnesota's $188 million investment is expected to bring about $1.2 billion in matching federal funds. Governor Dayton also signed an executive order removing the ban on applications for federal PPACA-related grants. Minnesota is expected to receive an exchange planning grant soon. While Governor Dayton cleared the way for the state to seek grants for implementing federal health reform, it is unlikely that state legislators will be passing bills to implement the federal health reform law unless absolutely necessary. Other pending bills of interest include anti-PPACA legislation, a bill requiring guaranteed issue in the individual market, creation of a defined contribution program for childless adults with incomes at or above 133 percent of FPL (reduction from current level of 250 percent), the prohibition of dental plan fee schedules for non-covered services, and an autism coverage mandate. In addition, Governor Dayton named a new Commissioner of the Department of Commerce, Minneapolis attorney Michael Rothman.NEVADA: The legislature convened on February 7 with a scheduled adjournment date of June 6. Governor Brian Sandoval will sponsor an exchange bill, although he opposes federal health care reform. His reasons include not wanting the federal government to take action in the state and the fact that the legislature will not meet in 2012. The Division of Insurance (DOI) has indicated that it will pursue federal reform measures, including external review. Other legislation of interest includes the establishment of a statewide health information exchange system and amending the requirements for reimbursement of out-of network services to comply with the PPACA.TEXAS: Governor Rick Perry delivered his State of the State speech last week, which included plans to suspend the State Historical Commission and the Commission on the Arts in addressing the state's $27 billion budget deficit. Speaking to a joint session of the legislature, Perry said the time has finally come to streamline state government. Perry's speech focused heavily on how strong the state's economy is, despite the deficit. According to Perry, Texas added more jobs in 2010 than any other state in the nation. That state-wide job growth occurred in the sectors of business, health care, manufacturing, hospitality, construction and energy. Perry's speech was highly critical of national politics, and he threatened to push back when Washington encroaches on states' rights. His budget proposal calls for cutting more than $2 billion in state spending on public education and another $2 billion in higher education, plus more than $2 billion in health and human services programs. Those cuts would come with much larger reductions in federal dollars, because states draw federal funding for programs such as Medicaid by spending state money.VERMONT: Newly-elected Governor Peter Shumlin's focus has been on reducing the state's projected $100 million budget deficit. Proposals to deal with the deficit include changes to the administration of the state's Catamount program, changes to Catamount reimbursement, imposing an assessment on managed care organizations, increasing the provider tax on hospitals, and imposing an assessment on dentists. The legislature is also considering a number of bills that would create a single-payer, government-run health care plan and require rate reviews. The bills include:Supported by the governor, H.B. 202 would establish Green Mountain Care and the Vermont Health Benefit Exchange, through which all state residents would be eligible for health benefits. After implementation of the Green Mountain single-payer system, private insurance companies would be prohibited from selling health insurance policies in that cover services also covered by Green Mountain Care.H.B. 80 would create a single-payer health care system called Ethan Allen Health. If the secretary of Human Services obtains a waiver from the exchange requirement, private insurance companies will be prohibited from selling insurance policies in the state for coverage of services covered by Ethan Allen Health. But it would not prohibit individuals from purchasing supplemental health insurance covering services not already covered by Ethan Allen Health.S.B. 57 would establish Green Mountain Care as a single-payer health care system, which will include coverage provided under a health benefit exchange, Medicaid, and Medicare.H.B. 146 would establish a public health care coverage option called Green Mountain Care that would require Vermont residents to have health care coverage at least equivalent to the actuarial value of Green Mountain Care and would assess a financial penalty against those who fail to maintain such coverage. The bill would institute a candy and soft drink tax as well as a 10 percent payroll tax on all employers with more than four employees to fund Green Mountain Care.
S.B. 56 and H.B. 165 would amend current rate review procedures to require written approval from the commissioner before a health insurance policy can be issued and to require that all rate and form filings be filed electronically. Rate changes would require approval by the commissioner prior to implementation and notice to plan members of rate changes and a 30-day comment period.H.B. 82 would require health insurers to disclose to the Department of Banking, Insurance, Securities, and Health Care Administration the fee schedules they negotiate with providers, and directs the department to post the information on its website.