Washington Healthcare Update

October 5, 2015

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This Week: Congress Avoids a Government Shutdown… House andSenate Approves Measure to Expand the Affordable Care (ACA) Act Small GroupMarket to 100 Employees…Affordable Care Act (ACA) Health Insurers toReceive Only 12.6 Percent Reinsurance Rate of Under Risk Corridors Program

1. Congress

House of Representatives


2. Administration

3. State Activities

4. Regulations Open for Comment

5. Reports

1. Congress


Congress Avoids a Government Shutdown

House and Senate Members avoided a government shutdown on Sept. 30, the day the 2015 fiscal year ended, by passing a short-term continuing resolution(CR)funding the government through Dec. 11. The House- passed CR without a controversial Tea-Party provision to defund Planned Parenthood, passed in avote of 277-151, relying on Democrats to pass the bill. The Senate passed the CR in a 78-20 vote. A spending fight is expected to resume soon, as memberstry to hash out a long-term plan for the budget.

House and Senate Approves Measure to Expand the Affordable Care (ACA) Act Small Group Market to 100 Employees

The House of Representatives on Sept 28 passed by voice vote the Protecting Affordable Coverage for Employees Act (PACE) and the Senate did the same onOctober 1. The White House has not signaled whether they will sign the legislation. Under the ACA, the definition of small employer would increase from1-50 employees to 1-100 employees. However, the legislation provides states the flexibility to expand the small group size. Both the House and Senatepassed the legislation by voice vote.

Insurers and business groups were concerned that the change which would have gone into effect January 1, 2016, would force employers to seek new coverageand disrupt the marketplace.

House Committees Begins Reconciliation Discussions to Target the Affordable Care Act (ACA)

House committees began the process to move reconciliation legislation and included several provisions related to the ACA. In the budget resolution passedby both chambers of Congress earlier this year, three House committees were given instructions for ” reconciliation” legislation that cuts a total of $3billion from the budget. The Ways and Means Committee passed itsreconciliation proposal on Sept. 29..That package includes repeal of the ACA’s individual and employer mandate repeal of the medical device and repeal of the “Cadillac” tax paid if the valueof an insurance policy exceeds a threshold. In addition, the package repeals the Independent Payment Advisory Board (IPAB), a board created by the ACA tomake cuts in health spending but has never been staffed.

The same day, the Energy and Commerce Committee passed t areconciliation proposal, to defund Planned Parenthood under Medicaid ( about $390 million per year to be replaced with $235 million in funding for community health centers) andthe ACA’s Public Health Fund.

The Committee on Education and the Workforce used its reconciliation markup to target the “auto-enrollment mandate.” ThisACA function requires employers with 200 or more full-time employees to automatically enroll new full-time employees in job-based coverage if the workerdoes not pick another employer plan or decline coverage within 90 days of their hire.

The three committees’ approved measures will be combined into one proposal and then will be sent to the House floor. President Obama is likely to veto thepackage. While the Senate is expected to also craft a reconciliation package, they have not yet begun to do so.

House Sends Clinical Trails Act to the President’s Desk

On Sept. 28, the House of Representatives passed the Ensuring Access to Clinical Trials Act of 2015” (H.R.209). The bipartisan billwould allow people receiving Supplemental Security Income (SSI) and Medicaid benefits to participate in clinical trials without jeopardizing theireligibility for those income-eligible benefits. An identical Senate bill, sponsored by Senate Finance Ranking Member Ron Wyden (D-OR), Finance Chair OrrinHatch (R-UT) and Sen. Edward Markey (D-MA), passed the Senate in July. The President is expected to sign the bill into law.

The legislation makes permanent a 2010 law which included a sunset provision ending the program after five years, so that its effects could be studied. TheGovernment Accountability Office (GAO) released a report analyzing the program last year and determined there weren’t any negative aspects.

House Passes Bill to Allow Individuals to Opt Out of Affordable Care Act (ACA) Individual Mandate for Religious Reasons

The House of Representatives approved H.R. 2061, the Equitable Access to Care and Health Act (EACH) on Sept. 28. This legislation extends the ACA’sreligious conscience exemption from the individual mandate to purchase health insurance to include individuals who rely solely on a religious method ofhealing and for whom the acceptance of medical health services would be inconsistent with their religious beliefs from the requirement to purchase andmaintain minimum essential health care coverage. This language is most often used to describe Christian Scientists.

The ACA currently contains a religious conscience exemption, but it extends only to groups that refuse all insurance programs, including Medicare andSocial Security, such as the Amish and some conservative Mennonite groups. Federal social legislation has traditionally made a special exemption provisionfor Christian Scientists. The legislation does not preempt state laws governing provision of medical services to children.

An identical Senate bill was introduced by Sen. Kelly Ayotte (R-NH). The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) costestimates show that, if signed into law by President Obama, the EACH Act would increase the federal deficit by $1.2 billion in the next decade.

House Ways and Means Committee Members Send Letter to Centers for Medicare and Medicaid Services (CMS) on Financial Solvency of the Affordable Care Act(ACA) Insurance Co-ops

On Sept. 30, House Ways and Means Oversight Subcommittee Chairman Peter Roskam (R-IL), Health Subcommittee Chairman Kevin Brady (R-TX), and Rep. AdrianSmith (R-NE) sent a letter to theActing Administrator CMS, Andrew Slavitt expressing concern over the lack of oversight on ACA Consumer Operated and Oriented Plans (CO-OPS). Co-ops, are atype of non-profit health insurer created by the ACA which can s offer health plans both through the health insurance exchanges and outside the exchanges.The letter asked CMS to disclose which co-ops have been placed on “enhanced oversight”. To date, four CO_OPS have announced that they will close. Membersare concerned about the $542.9 billion spent on those four CO-Ops. The lawmakers wrote, “We look forward to working with you to improve oversight,accountability, and transparency of the CO-OPs, and most importantly, to protect taxpayers who stand to lose when they fail.” 19 Insurance Co-ops currentlyoperate under the Affordable Care Act (ACA).

Bicameral, Bipartisan Letters Urges the Centers for Medicare and Medicaid Services (CMS) to Prevent Proposed Reimbursement Cuts to Radiation Therapy

In three separate letters, members of the House and Senate wrote to CMS’ Acting Administrator Andy Slavitt asking that a potential 6 percent cut to freestanding radiation therapy centers be prevented. CMS proposed this reduction in its’ 2016 Physician Fee schedule. Free standing radiation therapy centersserve nearly 40 percent of all cancer patients. Radiation therapy providers have seen a cumulative reduction in Medicare reimbursement of almost 20 percentover the past decade.

Members warned CMS that reimbursement rate cuts would be particularly onerous on patients diagnosed with breast and prostate cancer, cancers that have thehighest annual growth rate (after skin cancer). The American Society for Radiation Oncology has voiced concerns that the proposed cuts will limit access tocare. Sens. Richard Burr (R_NV) and Debbie Stabenow (D-MI), and Reps. Devin Nunes (R-CA), Paul Tonko (D-NY) and Robin Kelly (D-NY) led the letters.. Freestanding radiation therapy centers serve nearly 40 percent of all cancer patients due to convenience and the ability to solicit personalized care.Radiation therapy provides have seen an almost cumulative 20 percent reimbursement drop in the past decade.

The House letters can be foundhere andhere.

The Senate Letter can be foundhere.

House Energy and Commerce Health Subcommittee Holds Hearing on Three Medicare Bills

The House Energy and Commerce Subcommittee on Health held a hearing on Oct.1 to discuss three legislative proposals related to the Medicaid program

  • H.R. 1934, the Cancer Care Payment Reform Act of 2015 : Sponsored by Representative Cathy McMorris Rodgers (R-WA) and Steve Israel (D-NY), establishes a medical home demonstration for cancer care called the Oncology Medical Home Demonstration Project
  • H.R. 556, the Prevent Interruptions in Physical Therapy Act of 2015 : Introduced by Representative Gus M. Bilirakis(R-FL) and Representative Ben R. Lujan (D-NM). This legislation amends Medicare Part B to permit physical therapists the same latitude as other Medicare providers to to substitute another provider under their provider number in the absence of a provider for reasons such as illness, vacation, pregnancy or continuing medical education
  • H.R.___, To amend title XVIII of the Social Security Act : A discussion draft authored by Representative Greg Walden (R-OR), to make changes to the Medicare home health face-to-face encounter requirements:

Witness List

Dr. Bruce Gould MD
Community Oncology Alliance

Sarah Meyers CAE
Executive Director
Oregon Association of Health Care

Sandra Norby PT, AT
HomeTown Physical Therapy, LLC

A background memo detailing the bills can be found here

For more information or to view or watch the hearing, please visit energycommerce.gov

House Energy and Commerce Oversight Subcommittee to Hold Hearing on State Exchange Marketplaces

The House Energy and Commerce Subcommittee on Oversight and Investigations, chaired by Rep. Tim Murphy (R-PA), held a hearing on Sept. 29 entitled “ACAOverdue Checkup: Examining the ACA’s State Insurance Marketplaces.” Subcommittee members heard testimony from six states that have state based exchanges aspart of the Affordable Care Act (ACA). Members were particularly interested in whether states intended to repay ACA funds used to construct troubled stateinformation technology platforms for the state exchanges, particularly in states that abandoned the construction of their own exchanges in favor of usingfederal platform Healthcare.gov. and in the long term financial sustainability of the exchanges.

Witness List

Peter V. Lee
Executive Director
Covered California
State of California

Jim Wadleigh, Jr.
Chief Executive Officer
Access Health CT
State of Connecticut

Jeff M. Kissel
Executive Director
Hawaii Health Connector
State of Hawaii

Louis Gutierrez
Executive Director
Massachusetts Health Connector
State of Massachusetts

Allison O’Toole
Interim Chief Executive Officer
State of Minnesota

Patrick Allen
Department of Consumer and Business Services
State of Oregon

For more information or to view the hearing, visitenergycommerce.gov.


The Senate Health, Education, Labor, and Pensions (HELP) Committee Approves Mental Health Legislation

The Senate HELP Committee approved on a voice vote legislation,S. 1893 Mental Health Awareness and Improvement Act of 2015, that reauthorizesand makes targeted changes to programs related to awareness, prevention and early identification of mental health conditions and the promotion of linkagesto appropriate services for children, and youth. The bill focuses on suicide prevention, helping children recover from traumatic events, mental healthawareness for teachers and others and assessing barriers to integrating behavioral health and primary care. The bill also stresses efforts to assist statesand local communities in addressing mental health needs.

Introduced by Chair Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA), the bill has 22 cosponsors. The committee is expected to take up a muchmore comprehensive mental health reform bill authored by Sens. Chris Murphy (D-CT) and Bill Cassidy (R-LA) in the coming months.

Letter to the Department of Health and HumanServices (HHS) From Two Senate Committee Chairman: Adopt Stage Two of theElectronic Health Records Program and Finalize Stage Three No Sooner Than2017

Senate Health, Education, Labor, and Pensions (HELP) Committee Chairman Lamar Alexander (R-TN) and Commerce, Science, and Transportation Committee ChairmanJohn Thune (R-SD) sent a letter onSept. 28 urging the Administration to immediately adopt stage two modifications for the federal government’s program requiring doctors and hospitals tocreate electronic health records systems, and make the rules for stage three final not before Jan.1, 2017. “t… stage two requirements are so complex thatonly about 12 percent of eligible physicians and 40 percent of eligible hospitals have been able to comply. … The modified stage two rule will enable moreproviders to comply with the government’s requirements. It should be adopted immediately to give physicians and hospitals time to adapt to these hugechanges,” the letter said. They continued, “If the department does not delay making final the stage three rules and instead proceeds before it can measurethe impact of the modified stage two rule, it will be a missed opportunity to build support among providers.” The chairmen’s letter comes as a bipartisangroup of 96 Republicans and 20 Democrats in the House of Representatives in a separate letter to the Administration urged it to “pause” the process ofmaking stage three rules final.

Senate Health, Education, Labor, and Pensions (HELP) Committee Holds Hearing on Health Information Technology

The Senate Health, Education, Labor, and Pensions Committee (HELP) held a hearing with Department of Health and Human Services (HHS) witnesses on Oct. 1entitled “Achieving the Promise of Health Information Technology.” At the hearing Chairman Lamar Alexander (R-TN) offered Administration officialsfive reasonsto take more time before making final the stage 3 rule of the federal government’s program to require doctors and hospitals to create electronic healthrecords systems. “The whole purpose of this program is to benefit patients, so that they and their health care providers have quicker and better access totheir health histories and their doctors and hospitals and pharmacists can provide them with better care.” Chairman Alexander also used his time to pointout that the Merit-Based Incentive Payment System (MIPS) pays out penalties and bonuses based partially on meeting meaningful use. Meaningful use will be25 percent of a provider’s MIPS score.

In response, CMS Principal Deputy Administrator Patrick Conway noted the MIPS program, which was part of the Sustainable Growth Rate (SGR) replacement lawpassed earlier Congress, affords CMS the ability to look beyond an all-or-nothing approach to meeting meaningful use. Doctors have been continually askingfor more flexibility in the program so that a provider meeting the vast majority of requirements of the program will not be subject to tough penalties justfor missing one requirement. At the hearing, Sen. Bill Cassidy (R-LA) also announced that he and Sen. Sheldon Whitehouse (D-RI) plan to co-introduce a billon electronic health record interoperability the following week. The hearing was the committee’s sixth on electronic health records.

Witness List

Karen DeSalvo, MD, MPH, MSc
National Coordinator for Health Information Technology Department of Health and Human Services
U.S. Department of Health and Human Services

Patrick Conway, MD, MSc
Acting Principal Deputy Administrator Deputy Administrator for Innovation and Quality, Centers for Medicare and Medicaid Services Chief Medical Officer
Centers for Medicare and Medicaid

Bicameral, Bipartisan Letter Urges Centers for Medicare and Medicaid Services (CMS) Not to Make Medicare Reimbursement Rate Cuts for Colorectal CancerScreening

Separate House and Senate letters opposed CMS’ proposed reduction in Medicare reimbursement for colorectal cancer screening. The House letter was signed byalmost 100 members and the Senate letter was signed by 27 Senators. CMS proposed reducing reimbursement by ten to 200 percent in the proposed 2016 MedicarePhysician Fee Schedule

The House letter can be found here.

The Senate letter can be found here.

2. Administration

Centers for Medicare and Medicaid Services (CMS) Announces Medicare Part D Enhanced Medication Therapy Management (Enhanced MTM) Model

On Sept. 28, CMS’s Center for Medicare and Medicaid Innovation (CMMI) announced a model to teststrategies to improve medication use among Medicare beneficiaries enrolled in Part D.. The Part D Enhanced Medication Therapy Management (Enhanced MTM)model will assess the feasibility of providing selected Medicare Prescription Drug Plans (PDPs) with additional incentives and flexibilities to design andimplement innovative programs will better achieve the overall goals for MTM programs, including 1) improving compliance with medication protocols 2)reducing medication-related problems, such as duplicative or harmful prescription drugs, or suboptimal treatments; 3) increasing patients’ knowledge oftheir own medications and 4) improving communication among prescribers, pharmacists, caregivers and patients.

The Enhanced MTM model test will begin January 1, 2017 with a five-year performance period in 5 Part D regions: Region 7 (Virginia), Region 11 (Florida),Region 21 (Louisiana), Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming), and Region 28 (Arizona). Eligible stand-aloneprescription drug plans in these regions can apply to vary the intensity and types of MTM interventions they offer based on beneficiary risk level and seekout a range of strategies to individualize beneficiary outreach and engagement.

More information about the Enhanced MTM model test can be found here.

The Department of Health and Human Services (HHS) Announces $685 Million in Federal Funding for Regional Healthcare Networks

On Sept. 29, HHS Secretary Sylvia Burwell announced $685 million in grant awards to39 national and regional health care networks and supporting organizations in who will participate in the Transforming Clinical Practice Initiative. Theinitiative’s purpose is to equip more than 140,000 clinicians with the tools and support needed to improve quality of care, increase patients’ access toinformation, and reduce healthcare costs. The Transforming Clinical Practice Initiative is one of the largest federal investments designed to supportdoctors and other clinicians in all 50 states through collaborative and peer-based learning networks for primary and specialty physicians, nursepractitioners, physician assistants, clinical pharmacists, and their practices..

For a list of awardees and their project abstracts, visitcms.gov.

Affordable Care Act (ACA) Health Insurers to Receive Only 12.6 Percent Reinsurance Rate of Under Risk Corridors Program

On Oct. 1, HHSannouncedwhat payments will be made to insurers related to their risk corridors. Health insurers in the marketplaces created by the ACA will be reimbursed this yearonly 12.6 percent of the money they are owed under the law’s Risk Corridors Program. Based on current data from qualified health plan issuers’ riskcorridors submissions, HHS said issuers will pay $362 million in risk corridors charges, and have submitted for $2.87 billion in risk corridors paymentsfor 2014. HHS will begin collection of risk corridors charges in November, 2015, and will begin remitting risk corridors payments to issuers startingDecember, 2015. Reinsurance provides a safeguard against individuals with high medical costs – known as “high risk” – during the first three years of theACA’s insurance market reforms (2014-2016). All ACA-compliant, non-grandfathered plans on the individual market, both inside and outside the exchanges areeligible for reinsurance payments. A CMS regulatory impact analysis estimated that the reinsurance protection allowed insurers to price their premiums10-15 percent lower in 2014 than what prices would have been otherwise.

The Centers for Medicare and Medicaid Services (CMS) Has Initiated New Data Matching Initiative to Capture Double Enrollment in Federally SubsidizedExchange Plans and Medicaid

CMS released a frequently asked questions documenton Sept. 28 reporting that the agency has begun conducting Periodic Data Matching (PDM) in the Marketplace to help ensure consumers enrolled in Medicaid orCHIP coverage are not also accidentally enrolled in a an exchange plan with Advance Payments of the Premium Tax Credit (APTC) or Cost-Sharing Reductions(CSRs). The matching program alerts customers who are doubly enrolled and warns them that they need to end their exchange coverage and may