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Posts Tagged ‘ACA Section 1332’

Iowa files urgent ACA 1332 waiver request to preserve 2018 non-group market

June 15th, 2017 No comments

Facing the prospect of no health plan issuers offering coverage in the individual, non-group medical insurance market in 2018, Iowa is urgently asking the federal government for a state innovation waiver under Section 1332 of the Patient Protection and Affordable Care Act. The proposed stopgap measure by the state’s Insurance Division requests federal premium and cost sharing subsidies be used to fund the Proposed Stopgap Measure (“PSM”) Plan. The plan would offer a single standardized benefit plan with an actuarial value of 68 to 72 percent with premium subsidies determined by age and household income. It also proposes the federal Affordable Care Act funding support a reinsurance program for individuals incurring medical expenses greater than $100,000.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

California single payer bill would amalgamate federal, state health program funding

March 30th, 2017 Comments off

A California state lawmaker this week fleshed out proposed legislation that would create a single payer scheme of medical care financing in the Golden State named Healthy California. The proposed legislation would create Healthy California Trust Fund to fund medical care for all Californians and combine federal funding for health programs (Medicare, Medicaid, Children’s Health Insurance Program, Patient Protection and Affordable Care Act) as well as state funds. Waivers would be sought from the federal government as needed to redirect funding from the federal programs to the Healthy California Trust Fund.

A key part of the funding under the measure is federal approval of a waiver under Section 1332 of the Affordable Care Act that allows states to set up their own medical care financing schemes using federal dollars that would otherwise be available under the ACA such as subsidies for health plan premiums and out of pocket costs in the non-group market and expanded Medicaid eligibility. Vermont took a similar tack with a single payer plan but ultimately concluded it would require substantial state funding to an extent the program would not be politically feasible.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Feds encourage states to consider ACA Section 1332 waiver to fund reinsurance and high risk programs

March 13th, 2017 Comments off

The federal government is adopting a more flexible stance on state applications for waivers under Section 1332 of the Patient Protection and Affordable Care Act, particularly for states that want to create state reinsurance programs and high risk pools. Citing President Donald Trump’s January 20, 2017 executive order directing federal agencies to exercise maximum discretion possible within the law to reduce economic burdens imposed by the Affordable Care Act, the Health and Human Services Agency today encouraged states to utilize the Section 1332 state innovation waiver process to fund state reinsurance plans and high risk pools. “If a state’s plan under its waiver proposal is approved, a state may be able to receive pass through funding to help offset a portion of the costs for the high risk pool/state-operated reinsurance program,” HHS Secretary Tom Price wrote in a letter to state governors today.

Few states have shown interest in pursuing a Section 1332 waiver given the burdens of providing coverage on a par mandated by the Affordable Care Act while not requiring more federal funding than would otherwise be available under the law. Section 1332 allows the federal government to authorize states to opt out of most the law’s individual and small group health insurance market reforms including requirements to have a health benefit exchange, that plans provide specified essential health benefits as well as advance tax credit premium subsidies and reduced cost sharing for those households meeting income criteria. Also waivable are the individual and employer shared responsibility mandates. A budget reconciliation bill pending before Congress would zero out the penalties for noncompliance with those mandates.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Exchange plan subsidies face second major legal threat

May 16th, 2016 Comments off

Subsidies for qualified health plans (QHPs) sold on state health benefit exchanges are facing another significant legal threat, less than one year after the U.S. Supreme Court ruled in King v. Burwell that advance tax credit premium subsidies are available for all state health benefit exchanges, including those states that opted to allow the federal government to operate the exchange. The plaintiffs in that case unsuccessfully argued the language of Section 1311(d)(1) of the Affordable Care Act narrowly defined an exchange as a governmental agency or nonprofit entity that is “established by a State.” In King, the Obama administration argued and the high court agreed that read in the broader context of the law, the tax credit subsidies are intended to apply in all exchanges.

Citing King, the administration similarly contends in United States House of Representatives v. Burwell that context is key relative to Section 1402 of the Affordable Care Act. That section provides for supplemental subsidies in addition to advance premium tax credits for households earning between 100 and 250 percent of federal poverty levels. The additional subsidies limit out of pocket costs for households at that income level enrolling in a silver level QHPs — the most commonly selected metallic plan design. In House of Representatives, plaintiffs argue their funding is not a continuing appropriation and thus requires an annual appropriation as part of the federal budget.

The administration claims taken in the larger context of the Affordable Care Act, Section 1402 is ambiguous and must be read in context with Section 1401 that funds the advance tax credit premium subsidies via Section 36B of the Internal Revenue Code. The two funding mechanisms are intended to work tandem to make individual coverage more affordable to low income households, the administration posits. Disallowing funding for the supplemental cost sharing subsidies as the House seeks while leaving it intact for premium tax credits would produce an absurd outcome, it maintains.

In a ruling issued May 12, U.S. District Court judge Rosemary M. Collyer agreed with the House, finding the supplemental cost sharing subsidies must be annually appropriated. “Far from absurd, that is a perfectly valid means of appropriation” Collyer wrote, finding paying them for qualified silver QHP enrollees violates the Constitution’s allocation of spending power to Congress without a proper appropriation approved by Congress and the president.

The administration is expected to appeal Collyer’s ruling to the First U.S. District Court of Appeal. Because the unusual case involves a dispute between the legislative and executive branches over the power of Congress to appropriate funding under the Constitution, it’s possible it could go directly to the Supreme Court. In any case, Collyer’s ruling won’t likely have an impact on QHPs offered on the exchanges in 2017 given Collyer stayed the House’s requested injunction against further administration spending for the cost sharing subsidies pending appeals. The change in administrations in 2017 will also blunt the impact of the ruling given the next administration and Congress could opt amend or repeal the Affordable Care Act such as to moot the case.

According to this Urban Institute analysis, if Collyer’s ruling ultimately becomes the law of the land and the Affordable Care Act remains intact, it would force health plans to substantially increase premiums for silver plans in order to recover the lost federal funding for cost sharing subsidies since they would remain under the ACA’s requirement to offer silver QHPs with reduced cost sharing to eligible households. That premium increase would in turn boost advance premium tax credit subsidies that are pegged to the premium rate for the second lowest cost silver QHP offered on exchanges, according to the analysis.

States could also reassess their options under the ACA if the cost sharing subsidies remain unfunded given that a significant percentage of exchange enrollees rely upon them. They could opt to cover most of this population under “basic health plans” per ACA Section 1331 for low income households earning up to 200 percent of federal poverty and not eligible for Medicaid. They also have the option to waive the cost sharing subsidies under Section 1332 of the law affording states wide latitude to fashion their own state health plans provided they meet certain conditions of coverage and don’t entail additional federal funding.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Hawaii, Vermont seek ACA Section 1332 waiver of small business (SHOP) exchange requirement

February 19th, 2016 Comments off

Hawaii, which decades ago expanded access to health insurance by requiring employers to offer coverage to most workers, hopes to use its 1332 request to harmonize the ACA’s small business insurance rules with the state’s own, often more stringent standards, including by waiving the requirement to maintain a Small Business Health Options Program (SHOP) exchange. Similarly, Vermont is requesting to waive the ACA’s requirement to establish an online SHOP exchange, seeking instead to allow small employers to continue to purchase qualified health plans directly from insurers.

Source: Innovation Waivers and the ACA: As Federal Officials Flesh Out Key Requirements for Modifying the Health Law, States Tread Slowly – The Commonwealth Fund

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Colorado becomes second state to consider ACA Section 1332 waiver to fund single payer health insurance

December 3rd, 2015 Comments off

A recently approved ballot measure will give Coloradans the final say on whether to scrap the state exchange in favor of a single-payer system.

Source: Colorado voters set to decide the fate of health exchange – StateScoop

Colorado becomes the second state where the Patient Protection and Affordable Act’s Section 1332 waiver could be used to fund a single payer system starting in 2017. In this case, it would take the form of a proposed state-sponsored health insurance cooperative funded by a 6.67 percent employer payroll tax that’s up for voter ratification in November 2016.

According to the story, the tax would raise $25 billion per year. If the federal government approves the Section 1332 waiver — which allows states to opt out of public health benefit exchanges and the shared responsibility mandates on individuals and employers if the state can provide coverage that’s as accessible and affordable as under the Affordable Care Act — another $11.6 billion in federal funding could be provided annually to fund ColoradoCare.

Vermont was the first state that planned four years ago to transition from the exchange to a single payer system in 2017 under the 1332 waiver. That plan was abandoned early this year due to concerns over its financial viability and burden on the small New England state’s budget. In more populous Colorado and its larger tax base, it could be easier for the numbers to pencil out.

For a state-based single payer system, a key determinant of its actuarial viability is likely to be the health status of its residents. The numbers look propitious in the Rocky Mountain State, which has a strong outdoor exercise activities culture and ranks high on health status indicators nationally.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Massachusetts seeks federal OK to keep small group at 50 or fewer employees in 2016

May 18th, 2015 Comments off

Massachusetts has asked the federal Department of Health and Human Services to continue to allow the state to define its small group market as employers with 50 or fewer employees in 2016 as the state prepares to request a state innovation waiver application for an alternative plan for individual and small group health coverage under Section 1332 of the Patient Protection and Affordable Care Act. The law defines small employers as those employers with 100 or fewer full time equivalent (FTE) employees. However, Section 1304(b)(3) of the Affordable Care Act affords states the option – which all exercised – to set the metric at 50 or fewer employees for plan years 2014 and 2015.

Massachusetts Gov. Charles D. Baker made the request in an April 27, 2015 letter to Health and Human Services Secretary Sylvia Burwell. Baker cited the need to maintain stability in its merged individual and small group markets, citing premium rate increases for small employers under Affordable Care Act rules barring medical underwriting of small groups and the increased likelihood employers of 51 to 100 employees would opt to self insure in 2016. Both developments “will further exaggerate” instability in the state’s merged individual and small group markets and prompt Massachusetts to reconsider the continued operation of a merged market, Baker wrote.

(H/T to Elizabeth Elizabeth Osius of Manatt, Phelps & Phillips, LLP for the heads up on this development).

Baker’s letter follows a letter to Burwell earlier this year by 17 business groups and the National Association of Health Underwriters requesting the Affordable Care Act’s 2016 expansion of states’ small group health insurance market to employers of up to 100 employees be delayed until 2018. The groups warn broadening the scope of the small group market will lead to market disruption among health insurers that could limit employer coverage options as well as potentially result in premium increases.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Arkansas could be leader state on ACA Section 1332 waiver — but must act quickly

May 12th, 2015 Comments off

If Arkansas wishes to opt out of Patient Protection and Affordable Care Act requirements governing individual and small group health insurance market reforms and propose an alternative plan under Section 1332 of the law, it must act quickly in order to have such a plan in place by January 1, 2017 as allowed under Section 1332, a consultant’s report recommends. On that date, Arkansas’s existing federal waiver allowing it to use expanded Medicaid eligibility funding to subsidize the purchase of qualified health plans on its health benefit exchange expires at the same time it plans to launch a state-based exchange. The 1332 waiver could also be combined with a new Medicaid Section 1115 waiver as part of an omnibus reform plan as permitted by federal rules, depending on how the state chooses to provide medical coverage to its low income and medically frail residents.

Section 1332 provides for state innovation giving states the flexibility to opt out of most Affordable Care Act individual and small group health insurance market reforms including the requirements to have a health benefit exchange, that plans provide specified essential health benefits as well as advance tax credit premium subsidies and reduced cost sharing for those households meeting income criteria. Also waivable are the individual and employed shared responsibility provisions.

To qualify for a waiver from the federal government, states must demonstrate their programs would ensure individual and small group plans would offer coverage at least on a par with plans providing the 10 essential health benefits prescribed by the ACA. State programs would also have to ensure individuals and small employers would have access to coverage with affordable premiums and protections against “excessive” out-of-pocket costs (such as annual maximums) like those for ACA plans and cover a comparable number of residents as existing ACA plans.

States granted Section 1332 waivers are eligible for “pass through” federal funding operating like an annual block grant. The funding would cumulatively represent what state residents would otherwise receive under ACA rules for premium tax credits, cost-sharing reductions and small business credits.

Given the complexity of assessing various policy and waiver options and preparing and vetting the application, the report prepared by Public Consulting Group recommends Arkansas enact the required authorizing legislation to seek the waiver by June 2015 and to submit the waiver application to the federal government by October 2015. (H/T to Elizabeth Osius of Manatt, Phelps & Phillips, LLP for writing about the report).

“Section 1332 Waivers are new territory in state and federal healthcare policy. No such waiver has been applied for, denied, or approved as of the date of this writing,” the April 6, 2015 Public Consulting Group report notes. “Interpreting and negotiating what is permissible under Section 1332 will gain its first precedents in the months ahead. This paper serves to help assess options and plan activities should Arkansas wish to be the first, or among the first, to submit an application.”

According to the report, some of the policy options Arkansas could implement under a Section 1332 waiver include:

  • Continuous enrollment for individual plans instead of annual open enrollment periods;
  • Offering Medicaid plans on the state health benefit exchange;
  • Allowing employers to issue tax exempt vouchers to employees to purchase individual coverage;
  • Reduced penalties for large employers offering “skinny” plans that do not meet ACA employer shared responsibility requirements for minimum affordable coverage;
  • Liberalized eligibility requirements for those wishing to purchase catastrophic plans with less than 60 percent actuarial value.
 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

ACA Section 1332 state innovation waiver analyzed as political pressure relief valve

April 30th, 2015 Comments off

I’ve previously written about a little noticed Patient Protection and Affordable Care Act provision at Section 1332 of the law that could have major implications for how states implement the law. It’s now getting notice from a major think tank, the Brookings Institution, which analyzes the Section 1332 state innovation waiver provision as a political pressure relief valve for gridlocked Washington and for states that continue to have difficulty accepting the law’s prescriptions for reforming their health insurance markets that are mandatory for plan years 2014-16.

It’s a big deal because it allows states to dispense with several of the Affordable Care Act’s health insurance market reforms starting in 2017 including the shared responsibility mandates and the requirement that all states have a health insurance exchange serving individuals and small employers. But states must first persuade the federal government they can operate their own state programs providing coverage on a par with value and affordability as under the Affordable Care Act requirements. If successful, states would be eligible for federal funding for their proposed programs.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

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