VISIT STATE HEALTH COMPARE
Blog & News
SHARE Results from Sara McMenamin in American Journal of Preventive Medicine: ACA Improved and Expanded Medicaid Coverage of Smoking Cessation Treatment
May 15, 2018:According to a new article in the American Journal of Preventive Medicine, the Affordable Care Act (ACA) improved and expanded state Medicaid coverage of effective smoking cessation treatment, although many programs are not fully compliant with the law.
The analysis, which is based on a SHARE-funded study led by Dr. Sara McMenamin (University of California, San Diego), examined data collected from 50 State Medicaid programs and the District of Columbia using a 12-question web-based survey. The survey assessed each program’s smoking-cessation coverage and its compliance with the four sections of the ACA (i.e., Sections 4107, 4106, 2502, and 2001) that address the expansion of Medicaid coverage for smoking-cessation treatments to bring coverage into alignment with recommendations from the U.S. Preventive Services Task Force (USFSTF). The authors also examined benefits language documents from each state as well as state plan amendments.
Key Findings
- Section 4107 of the ACA: Smoking-Cessation Coverage for Pregnant Women
Section 4107 of the ACA requires coverage of smoking-cessation treatments for pregnant women, including all seven forms of pharmacotherapy and individual and group counseling. Sixteen states adding this comprehensive coverage post-ACA, bringing the total number of states offering ACA-compliant smoking-cessation coverage for pregnant women to 28 (i.e., 55% of states). Taken separately, coverage for pharmacotherapy increased from 26 states covering all seven drugs for pregnant women in 2009 to 47 states in 2017. Coverage for smoking-cessation counseling lagged coverage for pharmacotherapy, with coverage for both face-to-face group and individual counseling for pregnant women increasing from 16 states in 2009 to 28 states in 2017. Of note, the four states that offered no coverage for cessation services for pregnant women in 2009 added at least some coverage by 2017, such that all 51 Medicaid programs offered coverage for at least some pharmacotherapy and counseling treatments to pregnant Medicaid enrollees.
- Section 4106 of the ACA: Coverage of USPSTF-Recommended Preventive Services without Cost-Sharing
Section 4106 of the ACA offers a 1% increase in the Federal Medical Assistance Percentage (FMAP) if Medicaid programs fully cover USPSTF-recommended preventive services, including all effective smoking-cessation treatments, and remove cost-sharing. In all, 15 Medicaid programs have submitted a state plan amendment to implement Section 4106, and nine of these report smoking-cessation coverage in alignment with Section 4106. Prior to the ACA, only one Medicaid program provided smoking-cessation coverage in alignment with Section 4106.
- Section 2502 of the ACA: Smoking-Cessation Pharmacotherapy May Not Be Excluded from Medicaid Formularies
Section 2502 of the ACA prohibits states from excluding any FDA-approved pharmacotherapy from their Medicaid formularies. The number of Medicaid programs covering all recommended pharmacotherapy increased from 26 in 2009 to 48 in 2017.
- Section 2001 of the ACA: Coverage of Preventive Services, Including Smoking Cessation, under Medicaid Expansion
Section 2001 of the ACA requires Medicaid programs in expansion states to cover all USPSTF-recommended preventive services, including smoking cessation, without cost-sharing or prior authorization requirements. In all, 23 of the 32 expanded Medicaid programs covered all recommended smoking-cessation treatments for their Medicaid expansion population. However, two programs were not covering all the recommended pharmacotherapy, and nine were not covering both individual and group counseling. Additionally, four still required cost-sharing for their covered treatments, and 21 have prior authorization requirements for some or all of their covered smoking-cessation treatments.
Conclusion
Medicaid programs have made considerable progress in expanding coverage for smoking-cessation treatments for enrollees since the passage of the ACA. However, the four sections of the ACA that address smoking-cessation treatments have not been fully realized, and the authors note that additional guidance and clarification from the Centers for Medicare and Medicaid Services (CMS) may be needed regarding these sections in order to achieve full compliance with the law.
Read the full American Journal of Preventive Medicine article.
Publication
Results from the 2017 Minnesota Health Access Survey (Webinar)
Date: April 19, 2018
Time: 12:00 p.m. - 1:00 p.m. Central
Watch a recording of the event below, or download the presentation slides and the event transcript.
Event Description
These new estimates come from the Minnesota Health Access Survey (MNHA), which is administered biennially by the Health Economics Program at the Minnesota Department of Health (MDH) in conjunction with researchers from SHADAC in order to assess health insurance coverage and health care access across the state.
This webinar features researchers from MDH and SHADAC, who discuss the 2017 survey content, results, the context surrounding coverage trends and changes, and the characteristics of the Minnesota’s uninsured in 2017.
Resources
Minnesota's Uninsured in 2017: Rates and Characteristics
Speakers
- Kathleen Call, PhD
SHADAC Investigator and Professor, Division of Health Policy and Management, University of Minnesota School of Public Health - Stefan Gildemeister, MA
State Health Economist and Director, Health Economics Program, Minnesota Department of Health - Alisha Simon, MS
Supervisor, Access and Cost Containment Unit, Health Economics Program, Minnesota Department of Health
Blog & News
Highlights from the 2018 Health Insurance Exchange Open Enrollment Period (Infographic)
April 10, 2018:The Centers for Medicare and Medicaid Services (CMS) recently released a final report on enrollment-related activity in the individual marketplace exchanges during the 2018 plan year Open Enrollment Period (OEP) for all 50 states and the District of Columbia. The infographic below highlights key data points from the report.
Publication
Recent Changes in Health Insurance Coverage for Urban and Rural Veterans: Evidence from the First Year of the Affordable Care Act
Boudreaux M, Barath D, & Blewett LA. (2018). "Recent Changes in Health Insurance Coverage for Urban and Rural Veterans: Evidence from the First Year of the Affordable Care Act." Military Medicine 00. doi: 10.1093/milmed/usy053
This article provides an analysis of the impact of the Affordable Care Act (ACA) on health insurance coverage for veterans in states that chose to expand Medicaid and in non-expansion states as well as for urban and rural veterans using data from the 2013 and 2014 American Community Survey. The analysis found a substantial 24% relative decline in the rate of uninsurance for U.S. Veterans, from 9.3 to 7.1% between 2013 and 2014. Coverage gains in rural areas were due to gains in Medicaid and individual market coverage. Residence in a Medicaid expansion state was particularly influential for rural veterans, as the increase in the insured rate was three times larger in Medicaid expansion states versus non-expansion states.
Blog & News
State 1332 Waiver Reinsurance Proposals: Wisconsin Releases Draft 1332 Waiver Seeking $170 Million in Pass-Through Funding
March 30, 2018:Please visit our 1332 Waiver Reinsurance resource page for the most current information about state 1332 Waiver Reinsurance activities. We will continue to update this resource as new developments occur.
Seven states—Alaska, Minnesota, Iowa, Oklahoma, New Hampshire, Oregon, and Wisconsin—have released 1332 State Innovation Waiver Applications seeking federal pass-through funding for state-based reinsurance programs.
| Three Types of Reinsurance Programs | |
|---|---|
|
The reinsurance programs proposed in the 1332 Waivers are of three different designs. Iowa, Minnesota, Oklahoma, New Hampshire, Oregon, and Wisconsin's proposals are traditional reinsurance programs where claims in a specified corridor (e.g. $50,000–$250,000) are paid, minus a coinsurance rate; Alaska’s program is condition specific, with the state paying all claims for individuals with one or more of 33 specific conditions; and Idaho’s program combines state-funded, condition-specific reinsurance; condition-specific Medicaid eligibility for individuals below 400% FPL with complex medical needs; and individual-market premium and cost-sharing subsidies for individuals below 100% FPL. |
A seventh state, Idaho, released 1332 and 1115 waivers requesting condition-specific Medicaid eligibility for individual-market enrollees with complex medical conditions; the state also created a state-funded, condition-specific individual market high-risk pool.
As of February 20, 2018, three states have received approval of their 1332 Waiver reinsurance proposals (AK, MN, and OR), two states (OK and IA) submitted and withdrew their applications, one state (NH) did not submit its application after releasing a draft for public comment, and one state (ID) has released dual 1332/1115 Waivers for comment with the intention of submitting formal applications to CMS in 2018.
Below is a table comparing the design details and waiver status for each state’s proposed reinsurance program and a timeline of 1332 Waiver reinsurance proposal developments..
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1332 STATE INNOVATION WAIVERS FOR STATE-BASED REINSURANCE: PROPOSAL DESIGNS
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||||||||
|---|---|---|---|---|---|---|---|---|
| Alaska Comprehensive Health Insurance Fund | Minnesota Premium Security Plan | Iowa Stopgap Measure (ISM) | Oklahoma Individual Health Insurance Market Stabilization Program (OMSP) | New Hampshire 1332 Waiver Reinsurance Plan | Oregon Reinsurance Program (ORP) | Wisconsin Healthcare Stability Plan (WIHSP) | Idaho Complex Medical Needs Waiver | |
| REINSURANCE PROPOSAL | ||||||||
| Reinsurance Type | Condition-specific reinsurance | Traditional reinsurance | Traditional reinsurance | Traditional reinsurance | Traditional reinsurance | Traditional reinsurance | Traditional reinsurance | Condition-specific Medicaid eligibility, condition-specific reinsurance |
| Reinsurance Corridor | All claims from policyholders with one of 33 specific medical conditions | $50,000 – $250,000 | $100,000 – $3,000,000 | $15,000 – $400,000 |
$45,000 – $250,000 |
TBD – $1,000,000 | $50,000 – $250,000 | $25,000 – |
| Coinsurance Rate | 100% | 80% / 20% | 85% / 15% (Claims > $3 Million: 100%) |
80% / 20% | 40% / 60% | 50% / 50% | TBD (50% – 80%) | At least 20% |
| Legislation Enacted | HB 374 November 7, 2016 |
HF 5 April 4, 2017 |
No applicable state legislation | HB 2406 June 6, 2017 |
HB 469 July 10, 2017 |
HB 2391 July 5, 2017 |
SB 770 February 27, 2018 |
S1150 April 6, 2017 Enacting state legislation for waivers expected April 2018 |
| 1332 STATE INNOVATION WAIVER | 1115/1332 WAIVER | |||||||
| Waiver Status |
Submitted |
Submitted May 5, 2017 Approved September 22, 2017 Signed October 16, 2017 |
Submitted June 12, 2017 Submitted August 22, 2017 Amended September 22, 2017 Withdrawn October 23, 2017 |
Submitted August 16, 2017 Withdrawn September 29, 2017 |
Draft waiver released for public comment July 19, 2017 | Submitted August 31, 2017 Approved October 19, 2017 |
Draft waiver released March 13, 2018 | 1332 waiver released for public comment November 1, 2017 1115 waiver released for public comment November 22, 2017 |
| State Funding | $55 million annually (51.6% of total) |
$271 million annually (61.9% - 66.3% of total) |
$0 (0% of total) |
$16 million in 2018 $230 million over five years (14.2% of total) |
$32 million annually (71.4% of total) | $90 milion in 2018 $1.1 billion over ten years (68.5% of total) |
$30 million in 2019 | $16 million in 2019 for state-funded high risk pool |
| Source of State Funds | $55 million in initial funding from General Fund, then funded via assessments on all insurers: • Health: 6% of gross premiums less paid claims • Title: 1% of gross premiums • Other: 2.7% of gross premiums |
Dedicated funding from Health Care Access Fund (financed via 2% provider assessment) and General Fund | No state funding | Assessment on premiums charged by all health insurers and reinsurers | Annually-determined assessment on health insurers per covered life, necessary to fund reinsurance pool | 1.5% assessment on fully insured commercial major medical premiums | State general fund | Net losses of state reinsurance pool funded by annually-determined assessment on insurers |
| 1332 Funding Request | $51.6 million in pass-through funding (48.4% of total) |
$138 - $167 million in pass-through funding (33.7% - 38.1% of total) |
$70 million in pass-through funding for reinsurance in 2018 (100% of total) $396 million total waiver funding in 2018 |
$309 million in pass-through funding in 2018 $1,395 million over five years (85.8% of total) |
$12.8 million in pass-through funding for reinsurance (28.6% of total) | $35.66 million in 2018 $356.6 million over ten years (31.5% of total) |
$170 million in pass-through funding in 2019 (85% of total) | $0 for reinsurance. $613 million in 1332/1115 waiver funding |
| 1332 Funding Received | $58.5 million (2018) $332 million (2018-2022) |
$130.7 million (2018) $1.003 billion (2018-2020) |
$54.5 million (2018) | |||||
| INDIVIDUAL MARKET | ||||||||
| Marketplace Type 1 | Federally-facilitated Marketplace | State-based Marketplace | State-partnership Marketplace | Federally-facilitated Marketplace | Federally-facilitated Marketplace | State-based Marketplace with Federal Platform | Federally-facilitated Marketplace | State-based Marketplace |
| Medicaid Expansion Status | Expanded Medicaid 2 | Expanded Medicaid 3 |
Expanded Medicaid 4 | Did not expand Medicaid | Expanded Medicaid4 | Expanded Medicaid | Did not expand Medicaid | Did not expand Medicaid |
TIMELINE OF 1332 WAIVER REINSURANCE PROPOSAL DEVELOPMENTS
3-13-2018 Wisconsin releases Draft 1332 Waiver Application. Wisconsin released a draft of its 1332 Waiver Application, seeking $170 million in federal pass-through funding for its state reinsurance program, the Wisconsin Healthcare Stability Plan (WIHSP). The state anticipates that if approved, WIHSP would reduce 2019 individual market premiums by 10% relative to premiums if the plan were not approved.
2-6-2018 CMS sets Alaska and Oregon pass-through funding for 2018. CMS notified Alaska that the state would receive an estimated $58.5 million in pass-through funding for reinsurance in the 2018 calendar year. CMS had initially determined that Alaska would receive $48.3 million in pass-through funding for the state’s reinsurance program. Oregon will receive $54.5 million in pass-through funding for its reinsurance program, nearly $19 million more than the $35.7 million it was set to receive as of its waiver approval.
1-26-2018 CMS sets Minnesota pass-through funding for 2018. CMS notified Minnesota that the state would receive an estimated $130.7 million in pass-through funding for the state’s reinsurance program in calendar year 2018. This was $8.5 million less than the $139.2 million specified in CMS’s initial waiver approval.
11-2017 Idaho released its draft 1332 and 1115 Waiver Applications. Idaho released draft 1332 and 1115 Waiver Applications for public comment. The proposed program is a novel combination of a new Medicaid eligibility category for individuals below 400% FPL with complex medical conditions; a state-funded, condition-specific individual market high-risk pool; and extending individual-market premium tax credits and cost-sharing reductions to individuals below 100% FPL. The state projects that their proposal will cover an additional 21,000 individuals while reducing total federal expenditures by $2 million.
10-23-17 Iowa withdrew its 1332 Waiver Application. Iowa’s Insurance Commissioner Doug Ommen withdrew the state’s 1332 Waiver Application, citing overly restrictive 1332 Waiver requirements that prevented the state from implementing its Stopgap plan under terms that would be workable for the state.
10-16-17 Minnesota accepts 1332 Waiver terms. Minnesota Governor, Mark Dayton officially accepted the Special Terms and Conditions for the state’s 1332 Waiver, though he reasserted his strong disagreement with CMS’s interpretation of federal law that led to its decision to not pass through federal savings on funding for the state’s Basic Health Plan (BHP), MinnesotaCare. Gov. Dayton specified that in signing the STCs, he was not waiving Minnesota’s right to the full amount of its federal BHP funding based on the state’s argument outlined in an October 4 memo to CMS.
9-29-17 Oklahoma withdrew its 1332 Waiver Application. Oklahoma notified CMS that it was withdrawing its 1332 Waiver Application. Oklahoma blamed CMS for missing a mutually-agreed-upon September 25 deadline for approval necessary for the state to implement its reinsurance program before the 2018 plan year. CMS had previously determined the application to be complete and indicated that approval would be forthcoming by the September 25 deadline. The state plans to seek a 1332 Waiver for reinsurance in future years.
9-22-17 CMS approved Minnesota’s 1332 Waiver. CMS has approved Minnesota’s 1332 Waiver Application, giving the state $139 million in pass-through funding for reinsurance in 2018, and a total of $1 billion in funding over five years. This is the amount the federal government will save in premium tax credits and cost-sharing reduction payments due to Minnesota’s reinsurance program. However, as Gov. Mark Dayton anticipated in a September 19 letter to Secretary Price, CMS will not pass through the money it will save on funding for the state’s Basic Health Program (BHP), MinnesotaCare since BHP funding is based on 95% of the amount of premium tax credits and cost-sharing reductions that would have been provided to BHP enrollees. Though CMS does not specify how much funding the state will lose for MinnesotaCare, Gov. Dayton claims that the state would lose $369 million in BHP funding over two years, more than it would gain in pass-through funding for reinsurance. The state has 30 days from receipt of the approval letter to accept or reject the terms of approval.
9-17-17 Iowa submitted an amendment to its 1332 Waiver. Iowa provided a supplement to its 1332 Iowa Stopgap Measure to increase the cost sharing subsidies available to individuals with incomes between 133–150% FPL. The state expects that the additional subsidy will increase participation of young, healthy individuals in its individual market, improving the risk pool and keeping premiums down. Because of this improved risk pool, the state is decreasing its reinsurance pass-through funding request from $80 million to $70 million.
8-31-17 Oregon submitted its 1332 Waiver Application. Oregon’s waiver seeks pass-through funding for its reinsurance proposal. $90 million in annual state funding for reinsurance plan is paid for through a 0.3% assessment levied on major medical premiums and through excess fund balances in two state programs. The state is seeking more than $30 million annually in federal pass-through funding. The reinsurance plan has a coinsurance rate of 50% and a cap of $1 million. The attachment point is to be determined.
8-16-17 Oklahoma submitted its 1332 Waiver Application. The Department of Health and Human Services submitted Oklahoma’s 1332 waiver, the Individual Health Insurance Market Stabilization Program (OMSP). The OMSP will have a broad corridor of $15,000 – $400,000 and will be largely funded with federal pass-through funding, with a smaller portion coming from a state assessment on health insurers.
8-1-17 Minnesota released preliminary individual market premiums. The Minnesota Department of Commerce published anticipated premium increases by health plans with and without reinsurance. With state reinsurance, plans expect that 2018 premiums could be modestly higher (largest increase 11.4%) to substantially lower (largest decrease 40.8%) than 2017 premiums. Without state reinsurance, plans project much larger increases in 2018 premiums.
7-19-17 New Hampshire released its Draft 1332 Waiver Application. The New Hampshire Department of Insurance released a draft of its 1332 Waiver application for public comment. The waiver proposes a traditional reinsurance program with a corridor of $45,000 – $250,000 and a 40% / 60% coinsurance rate. The application seeks $12.8 million in federal pass-through funding.
7-14-17 Oklahoma released its Draft 1332 Waiver Application. The Oklahoma Department of Insurance released a draft of its 1332 Waiver Application for public comment. Oklahoma’s 1332 waiver proposal includes reinsurance along with broader reforms to its individual market. The state is awaiting further actuarial analysis before determining its reinsurance plan’s corridor, coinsurance rate, and level of pass-through funding. Oklahoma’s proposal is a traditional reinsurance plan funded by assessments on health insurers.
7-7-17 CMS approved Alaska’s 1332 Waiver Application. CMS notified Alaska that its 1332 Waiver Application had been approved. The state was awarded $48.3 million in federal pass-through funding in 2018, and a total of $322 million over five years.
1 Kaiser Family Foundation. “State Health Insurance Marketplace Types, 2017.” http://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/.
2 Expanded Medicaid September 1, 2015
3 Minnesota also has MinnesotaCare, the Basic Health Program (BHP) for individuals 138–200% FPL.
4 Expanded Medicaid with Section 1115 Waiver
