Tag: healthcare

Q&A: Implications of the Ruling on the ACA’s Preventive Services Requirement

Note: This post was updated on April 4, 2023, to include additional details and a table showing potentially affected preventive services.

On March 30, 2023, a judge in the U.S. District Court in the Northern District of Texas issued a final judgment in a court case challenging the provision of the Affordable Care Act (ACA) that requires most private health plans to cover a range of preventive services without any cost-sharing for their enrollees. Having concluded in September that aspects of the requirement were unconstitutional and violated religious rights, the judge’s remedy in the Braidwood Management v. Becerra imposes new limits on the government’s ability to enforce those requirements nationwide. This Q&A summarizes some of the key issues related to the ruling.

What does the ruling mean for the public?

With about 100 million privately insured people using preventive services required by the ACA to be covered without out-of-pocket costs, the preventive services coverage requirement is the provision of the ACA that affects the broadest number of people, and it has been enormously popular with the public. Because of the ACA requirement, the vast majority of private health plans have to cover a range of preventive services and cannot impose deductibles or copays for them. If the ruling stands, over time, millions of people could end up paying more for preventive care and some may lose access to certain services. However, as sweeping as the ruling is, it does not completely and immediately wipe out preventive services coverage under the ACA.

That’s because the ruling applies specifically to services recommended by the US Preventive Services Taskforce (USPSTF) that were made after 2010 when the ACA was enacted. The ruling would not overturn coverage requirements for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), women’s preventive health services (such as contraception, well women care and prenatal care, breastfeeding support services, and intimate partner violence screening) recommended by the Health Resources and Services Administration (HRSA),  or services for children and young adults recommended by Bright Futures, though the plaintiffs had asked that those be struck down as well and that decision could be appealed. The ruling also only applies to updates to or new USPSTF recommendations issued since March 2010, when the ACA was enacted. It would effectively lock in place coverage requirements based on evidence from 13 years ago.

The ruling separately finds that the mandate to cover pre-exposure prophylaxis (PrEP), a medication taken to prevent HIV, violates the plaintiffs’ religious rights under the Religious Freedom Restoration Act (RFRA). While the RFRA remedy is limited specifically to the plaintiffs, because PrEP was recommended by the USPSTF after 2010, the medication and certain ancillary lab services can now be subject to out-of-pocket costs across all health plans and plans could elect to drop coverage altogether.

Coverage will not necessarily change immediately. Although the ruling is effective immediately, in many cases, health plan contracts are in place for the calendar year, and employers do not typically make changes to coverage or cost midyear. (It may be easier for plans to change formularies to allow for cost-sharing with respect to impacted drugs.)

Read the full article with details about changes at KFF.

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Medicare’s Mental Health Coverage: What’s Included, What’s Changed, and What Gaps Remain

How prevalent are mental health issues among Medicare beneficiaries?

About one in four Medicare beneficiaries live with mental illness — conditions such as depression, anxiety, schizophrenia, and bipolar disorder — but only 40 percent to 50 percent receive treatment.1 The prevalence of mental illness is about equal among beneficiaries enrolled in traditional Medicare (31%) and those in Medicare Advantage plans (28%), although variation in data sources and measurement make comparisons difficult.2

Mental illness is experienced most by those beneficiaries under age 65 who qualify for Medicare via disability, as well as by low-income beneficiaries dually eligible for Medicare and Medicaid.3 It is also more pervasive in beneficiaries from American Indian/Alaska Native and Hispanic communities relative to other racial and ethnic groups.4

Which mental health services does Medicare cover?

Medicare covers both outpatient and inpatient services as well as prescription drugs to treat mental illness.5 Traditional Medicare and Medicare Advantage plans generally follow the same coverage rules, and some also cover additional services, like grief counseling, or offer other tailored benefits through special needs plans catering to beneficiaries with mental illness.6

Inpatient services. Medicare Part A covers inpatient mental health services in both general hospitals and psychiatric hospitals, but the latter is limited to 190 total days per beneficiary across their lifetime. Traditional Medicare beneficiaries pay a deductible and coinsurance for each benefit period, which, for hospital services, begins on the day of admission and ends after a beneficiary has had no inpatient care for 60 consecutive days. Cost-sharing requirements vary across plans for Medicare Advantage enrollees.

Outpatient services. Medicare Part B covers outpatient mental health services delivered by psychiatrists or other physicians, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. The services covered include standard services like psychiatric evaluation, individual and group therapy, and medication management. After paying their annual deductible, traditional Medicare beneficiaries pay 20 percent of the Medicare-approved amount for covered services. As with inpatient services, cost-sharing requirements vary across Medicare Advantage plans.

Medication. For traditional Medicare beneficiaries, mental health medications are covered by Medicare Part D. Beneficiaries in a Medicare Advantage plan also may have a Part D prescription drug plan or another drug plan that follows Part D rules. All Medicare drug plans are required to cover antidepressant, anticonvulsant, and antipsychotic medications, as well as a wide range of other psychotropic medications like anti-anxiety drugs. Specific medications covered and out-of-pocket costs vary by drug plan.

Read the full article from the Commonwealth Fund.

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About 5 Million Uninsured People Could Get ACA Marketplace Coverage Without a Monthly Premium – But They Would Have to Enroll Soon

About 5 million uninsured people across the country could get coverage through an Affordable Care Act Marketplace health plan with virtually no monthly premium if they enroll soon, a new KFF analysis finds.

In most states, open enrollment runs through January 15, with tax credits available to help eligible low- and middle-income people afford coverage. Those tax credits would offset the full monthly premium for the lowest cost plan or plans for millions of uninsured residents, the analysis finds.

Free or nearly-free premium silver plans with very low deductibles are available to all Marketplace subsidy-eligible enrollees with incomes up to 150% of poverty ($20,385 for individuals or $41,625 for families of four enrolling in 2023).  In some cases, there could be a small extra charge – usually no more than a few dollars per month – for non-essential benefits covered by the plan.

In some parts of the country, people with incomes above 150% of poverty can also get free or nearly free silver plans, with somewhat less generous cost-sharing reductions. For example, as can be seen in the interactive map, a 40-year-old making $25,000 per year (184% of poverty) could get a free or nearly free silver plan with a smaller cost-sharing reduction in about 8% of counties, excluding counties where individuals are eligible for Medicaid or Basic Health Program (BHP) plans. Less generous bronze plans with higher deductibles are often available without a premium at even higher incomes.

KFF has an online calculator that estimates the tax credits and premiums available to individuals and families based on their age, income, and location, and maintains more than 300 frequently asked questions about open enrollment, the health insurance marketplaces and the ACA.

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Care Coordinators: MCOs’ Best Kept Secret

For families who have children with complex health care needs, coordinating all the appointments, medications, and therapies can be difficult. When an individual has several doctors and specialists that they regularly see, the help of a care coordinator can be invaluable. A care coordinator, or patient care coordinator, is a health professional employed by an MCO, or managed care organization, to oversee complex care cases. They can help with getting needed appointments, acquiring resources outside of prescriptions, ensuring that medications are easily available and do not have any interactions, and help families have better peace of mind that all of their medical practitioners are on the same page.

Care coordinators are available to many patients, but they are rarely given as an option to overtaxed patients or patients’ parents. Primary care physicians sometimes recommend a care coordinator to help a patient or family, but as they are not familiar with every aspect of a patient’s life and health care, they will often assume that a family does not need a care coordinator when they would be greatly aided by having one. For those with a strong connection to a primary provider, asking them to request a care coordinator for their healthcare can be an efficient way to start the process. While a primary care physician is often the one to initiate the assistance of a care coordinator, is possible for a patient or their family to request care coordination on their own.

The process for requesting a care coordinator is different through different health care systems. The majority of individuals on Medicaid, also known as Apple Health, have their healthcare covered by an MCO. Calling the MCO’s customer service line is often the first step in getting a care coordinator.  The phone numbers of the five MCO’s that oversee apple health in Washington state are as follows: Amerigroup at 1-800-600-4441, Community Health Plan of Washington at 1-800-440-1561, Coordinated Care of Washington at 1-877-644-4613, Molina Healthcare of Washington at 1-800-869-7165, and UnitedHealthcare Community Plan at 1-877-542-8997.  If you are unsure which MCO is in charge of your healthcare, view our video on Who is in Charge of Your Apple Health Healthcare? If there are problems in getting through to your MCO, you can call the Health Care Authority, that oversees all Washington Medicaid MCOs, at 1-800-562-3022.

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Who is in Charge of Your Apple Health Healthcare?

For individuals enrolled In Washington State Medicaid, also known as Apple Health, understanding who manages their medical care is not always easy.  In almost all cases, the management of care for people with Apple Health is delegated to an MCO, or Managed Care Organization. These are large for-profit organizations that often have a large infrastructure, making it confusing and difficult to find information or direction.

There are five MCO’s under Apple Health in Washington.  They are Amerigroup Washington, Community Health Plan of Washington, Coordinated Care of Washington, Molina Healthcare of Washington, and UnitedHealthcare Community Plan.  All of these MCOs are available statewide, except UnitedHealthcare Community Plan, with is only available in the western half of the State.  For anyone in the foster care system, they are automatically enrolled in Coordinated Care of Washington and this coverage will follow them until they are 21. Health Care Authority has a Service Area Matrix to view what MCOs are available in each county.

Under some circumstances a person on Apple Health will not be put into an MCO. If an individual is American Indian/Alaska Native they can view their options on the Health Care Authority’s American Indians and Alaska Natives page. Other non-MCO Apple Health patients will have a distinct services card that looks the card shown:

For those patients, review the Health Care Authority’s Handbook on Coverage Without a Managed Care Plan for information about how to receive services.  It is also possible to call them at 1-800-562-3022.

For those who do not remember which MCO they or their children are signed up with, it might have been done automatically for them when the initial roll out happened in 2014 or when they first became eligible for Apple Health under the ACA.  The switch to managed care was fully implemented in 2020.  Here are three ways in which to find out which MCO is overseeing an individual’s care:

  1. Review your Provider One Card to see which MCO is listed. Individuals who are on MCO-managed Apple Health will have the name and/or logo of the MCO on the Provider One card, like the example

In this case, UnitedHealthcare is the MCO.  The PCP listed is the Primary Care Physician, or a patient’s main doctor, and the PCP phone number listed can be called to schedule visits and ask medical-related questions.

  1. If the provider card is missing, call: 1-800-562-3022 and choose option 1 for self-service, then option 1 for services card. They can help replace the provider card and help enrollees get the services they require.
  2. Call the Health Care Authority Customer Service Line at 1-800-562-3022.

It is important to note that everyone enrolled in Apple Health within one household must be on the same managed care plan. Provider One cards are usually sent out once a year to enrollees and there is a number on the card to call for customer service. Below is the Apple Health managed care plan contact information:

Amerigroup (AMG)1-800-600-4441
Community Health Plan of Washington (CHPW)1-800-440-1561
Coordinated Care of Washington (CCW)1-877-644-4613
Molina Healthcare of Washington, Inc. (MHW)1-800-869-7165
UnitedHealthcare Community Plan (UHC)1-877-542-8997

All Apple Health enrollees have the right to change their MCO at any time, with no fee and with no gap in coverage. The shift usually occurs by the 15 of the following month, but the Provider One portal can help if there are challenges. There are several ways to switch plans:

If considering changing to a different MCO, visiting other MCOs websites or calling their information line with some questions can be useful. It is helpful to see what hospitals, urgent care facilities, specialists, and therapists are covered. Not all physicians or medical facilities that take Apple Health are contracted with all MCOs.

View our video on Who is in Charge of Your Apple Health Healthcare?

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Primary Care in High-Income Countries: How the United States Compares

Primary care providers (PCPs) serve as most people’s first point of contact with the health care system. These clinicians build relationships with their patients over time and help coordinate care delivered by other health care providers.1 Evidence shows that a strong foundation of primary care yields better health outcomes overall, greater equity in health care access and outcomes, and lower per capita health costs.2

But in the United States, decades of underinvestment and a low provider supply, among other problems, have limited access to effective primary care.3 This brief highlights gaps in the U.S. primary care system by comparing its performance to systems in 10 other high-income countries. We draw on data from the Commonwealth Fund’s 2019 and 2020 international surveys, along with data from the Fund’s 2020 International Profiles of Health Care Systems. (See “How We Conducted This Study” for further details.)

Highlights

  • U.S. adults are the least likely to have a regular physician or place of care, or a longstanding relationship with a primary care provider.
  • Access to home visits or after-hours care is lowest in the U.S.
  • U.S. primary care providers are the most likely to screen for social service needs.
  • Half of U.S. primary care physicians report adequate coordination with specialists and hospitals — around the average for the 11 countries studied.

Read the full article from the Commonwealth Fund.

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Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead

The Biden administration and state officials are bracing for a great unwinding: millions of people losing their Medicaid benefits when the pandemic health emergency ends. Some might sign up for different insurance. Many others are bound to get lost in the transition.

State Medicaid agencies for months have been preparing for the end of a federal mandate that anyone enrolled in Medicaid cannot lose coverage during the pandemic.

Before the public health crisis, states regularly reviewed whether people still qualified for the safety-net program, based on their income or perhaps their age or disability status. While those routines have been suspended for the past two years, enrollment climbed to record highs. As of July, 76.7 million people, or nearly 1 in 4 Americans, were enrolled, according to the Centers for Medicare & Medicaid Services.

When the public health emergency ends, state Medicaid officials face a huge job of reevaluating each person’s eligibility and connecting with people whose jobs, income, and housing might have been upended in the pandemic. People could lose their coverage if they earn too much or don’t provide the information their state needs to verify their income or residency.

Medicaid provides coverage to a vast population, including seniors, the disabled, pregnant women, children, and adults who are not disabled. However, income limits vary by state and eligibility group. For example, in 2021 a single adult without children in Virginia, a state that expanded Medicaid under the Affordable Care Act, had to earn less than $1,482 a month to qualify. In Texas, which has not expanded its program, adults without children don’t qualify for Medicaid.

State Medicaid agencies often send renewal documents by mail, and in the best of times letters go unreturned or end up at the wrong address. As this tsunami of work approaches, many state and local offices are short-staffed.

Read the full article from KHN.

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Determining the Safety of a Hospital or Medical Provider

Choosing a new hospital or provider is difficult, and safety is often a main concern. While there are several ways to look at safety information surrounding providers and clinics, there is no consensus as to the best approach. Here are some ways to evaluate the safety of your health care.

Medicare penalizes hospitals that have high rates of infections and patient injuries.  The information which hospitals the federal government has penalized (764 hospitals last year) is publicly available and can be viewed on KFN. However, the hospital industry has issues with penalties, saying that it creates an arbitrary cutoff for which institutions get punished and which don’t.

The Leapfrog Group has collected, analyzed, and published hospital data, and their 2021 Leapfrog Hospital Safety Grades include 49 Washington Hospitals.  U.S. News & World Report publishes a “Best Hospitals in Washington” ranking.  However, it does not rate the safety of the hospital, but the health outcomes and specialists that it employs.

Evaluating doctors is more difficult, as negative reviews given by patients cannot be commented upon by the care provider, due to HIPAA regulations. The Washington Department of Health regularly reports on any disciplinary actions against a health care provider on their newsroom page.  On their website, it is also possible to look up a health care provider license to view a health care provider’s license status, the expiration and renewal date of their credential, disciplinary actions and copies of legal documents.

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The No Surprises Act Begins January 2022: This is What You Can Expect

The “No Surprises Act,” which establishes new federal protections against most surprise out-of-network medical bills when a patient receives out-of-network services during an emergency visit or from a provider at an in-network hospital without advance notice, will take effect next month. A new KFF brief outlines what to expect in 2022, summarizing key provisions that will be implemented.

Most adults (2 in 3) say they worry about unexpected medical bills and among privately insured patients, about 1 in 5 emergency claims and 1 in 6 in-network hospitalizations include at least one out-of-network bill. The new federal protections will apply to most surprise bills for emergency care, as well as for non-emergency services provided at in-network facilities, potentially helping alleviate this worry.

The No Surprises Act prohibits providers from billing patients more than the applicable in-network cost sharing amount in these situations. Starting in 2022, providers will need to find out patient’s insurance status before submitting the surprise out-of-network bill directly to the health plan. However, patients can give written consent to waive their rights under the No Surprise Act and be billed more by out-of-network providers. It is expected this should only happen in limited circumstances.

The brief also describes procedures to arrive at payment amounts for surprise bills, including use of an independent dispute resolution (IDR) system. Under this system, it is likely that out-of-network payments will be close to the median rate that health plans pay for in-network services, and this would moderate health plan premiums overall. However, suits filed by provider organizations are pending and could result in further regulatory changes or delay implementation of the law.

If a patient receives what they believe is a surprise bill, the new brief highlights protections, and ways to seek help. This is a complex law, with enforcement being conducted in a variety of ways, both by federal and state agencies.

The No Surprises Act allows consumers to appeal disputes over coverage of surprise medical bills to an external reviewer. Another new KFF brief looks at the process for consumer appeal rights under the Affordable Care Act (ACA), which would also be used for surprise bills. Federal law gives consumers the right to appeal health plan claims denials and other adverse decisions, including the incorrect application of cost sharing, although limits apply. This brief describes consumer access to appeals and limits on appeal rights that have been adopted through federal regulations.