Health Care Reform Implementation Update November 18, 2014

Over the past several days, the second open enrollment period through the Affordable Care Act’s (ACA’s) health insurance exchanges began; Republican lawmakers, now with majorities in both the House and the Senate, explored legislative avenues for rolling back or delaying parts of the Affordable Care Act (ACA); and the Supreme Court agreed to hear a case that challenges the ACA’s subsidies in all states without state-run exchanges.


With a new Congress there will be a shift of committee leadership in both the House and the Senate. Of particular note for health care are changes to leadership at the Senate Health education Labor and Pensions (HELP) Committee and the Senate Finance Committee. Retiring Senate HELP (HELP) Committee Chair Senator Tom Harkin (D-Iowa) is likely to be replaced by Senator Lamar Alexander (R-Tenn.), who is currently the Ranking Member on the HELP committee. For the Senate Finance Committee, which also oversees health care policy, Senator Ron Wyden (D-Ore.) will likely be replaced by Senator Orrin Hatch (R-Utah).

Some Capitol Hill staff members have recently reported that the end of this congressional session, known as a “lame duck” session, could present the best opportunity for repealing the sustainable growth rate (SGR) formula. Repealing the SGR, also known as a permanent “doc fix,” would require a new method for determining the correct physician fee schedule in a given year – and more challengingly, a way to pay for it. Although there has been continued congressional support for permanently repealing the SGR, there is no agreement on an offset for the cost of this repeal. Some in Congress have raised the idea of passing permanent repeal without an offset; however, other legislators and their staffs do not think this is a good strategy.


On November 7, CMS announced the final methodology that it will utilize for its Dialysis Facility Compare (DFC) Star Ratings Program. CMS provided dialysis facilities that participate in Medicare with a preview of their ratings, which the facilities can review. The agency also announced that it expected to begin posting DFC ratings on its website in January of 2015.

CMS said that it had matched 95 percent of the enrollment files from’s first enrollment period (for 2014) with insurer records. On December 15, individuals who have not enrolled in a new plan will be automatically enrolled in the same type of plan they had previously enrolled in. The agency said it would continue to work with insurers to ensure that its records are accurate.

On November 13, the Government Accountability Office released a report on the Small Business Health Options Program (SHOP). GAO reported that enrollment in SHOPs was lower than CMS and stakeholders expected. By June 1, 2014, the 18 states that had created their own SHOPs had enrolled 76,000 individuals. Data was not available for federally facilitated SHOPs.

On November 10, CMS issued a Proposed Decision Memo, in which it proposed to allow Medicare coverage for low-dose computed tomography (LDCT) scans on an annual basis for Medicare beneficiaries between 55 and 74 years of age who smoked a minimum of one package of cigarettes per day for 30 years.

On November 10, CMS said that it expected between 9 and 9.9 million individuals to enroll in ACA health coverage during the 2014-2015 open enrollment period — a figure that is 3 million individuals less than what was previously projected by the Congressional Budget Office. The lower figure is the result of a slower than expected movement from employer-sponsored and individual coverage outside of the federal exchange.

On November 6, the Health Resources and Services Administration (HRSA), within HHS, announced that it had awarded $51.3 million in funding to 210 health centers across the country to provide behavioral health services, including hiring mental health professionals and expanding the provision mental health and substance abuse services.

During the Medicare Payment Advisory Commission’s (MedPAC’s) most recent public meeting, the commissioners discussed recommending to Congress a per-beneficiary per month payment incentive for primary care providers. The incentive, which would be in the amount of $31 per month, would replace the current Medicare primary care incentive payment, which expires at the end of next year. The Commission plans to vote on this recommendation at its December meeting.


On November 7, the Supreme Court announced that it would hear the King v. Burwell case. The plaintiffs in this case argue that subsidies for ACA exchanges are only allowed in states with state-run exchanges and that the federal government cannot provide such subsidies. Given that only 13 states currently run their own exchanges, if the Supreme Court ruled in the plaintiff’s favor, millions of Americans would become ineligible for subsidies. The Supreme Court is expected to hear the case in the spring and rule by the end of June 2015.

On November 14, the U.S. Court of Appeals for the District of Columbia ruled that nonprofit religious organizations must officially opt-out of providing contraception coverage to their employees. The plaintiff, a local D.C. Catholic diocese and several of its affiliated organizations, brought the case to express its objection to the opt-out requirement under the ACA, which triggers contraception coverage from the government, instead of simply being able to exclude contraception coverage in their offered health plans. The plaintiffs argued that by participating in the process to officially opt-out, that this was in turn condoning the use of contraception. The court unanimously disagreed, and ruled that the opt-out provision was not overly burdensome to nonprofit organizations and that it adequately expressed a nonprofit’s objection to providing contraception coverage.


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