House #COVID19 #TakeResponsibilityAct offers 100% FMAP to non-expansion states, reinstates Risk Corridors & more!

Besides effectively baking in a more-generous version of H.R. 1868 (Rep. Lauren Underwood's #KilltheCliff bill which I've been pushing for so hard for over a year now), the House Democrats' "Take Responsibility for Workers and Families Act" coronavirus stimulus/relief bill also includes some other important ACA-related provisions. Some of these are temporary, others would be permanent.

The full bill itself is a whopping 1,400 pages and includes hundreds of provisions which aren't connected to the ACA, of course; and even many of the healthcare-related provisions aren't specific to the ACA. However, there are a number of items which definitely are. The summary of the bill is 56 pages all by itself; here's all of the healthcare system specific items. I've highlighted the ones which are most ACA-centric:

TITLE I – MEDICAID

Sec. 101 – Increasing Federal support to State Medicaid programs during economic downturns. Creates a mechanism that will automatically increase federal payments to state Medicaid programs if a state experiences an increase in the state unemployment rate.

Sec. 102 – Limitation on additional Secretarial action with respect to Medicaid supplemental payments reporting requirements. Prevents the Secretary of Health and Human Services (HHS) from finalizing the Medicaid Fiscal Accountability Regulation (MFAR) until two years after the end of the public health emergency.

Sec. 103 – Authority to award Medicaid HCBS grants to respond to the COVID-19 public health emergency. Authorizes the Secretary to award grants to states to support activities that strengthen their home- and community-based services (HCBS) benefit.

Sec. 104 – Delay in reduction of FMAP for Medicaid personal care services furnished without an electronic visit verification system. This section, for the duration of the public health emergency, suspends reductions in the federal medical assistance percentage (FMAP) for states that are not in full compliance with the electronic visit verification requirements

Sec. 105 – Coverage at no cost sharing of COVID-19 vaccine and treatment. Ensures that adult Medicaid beneficiaries receiving traditional Medicaid benefits have access to a future COVID-19 vaccine without any out-of-pocket costs. It also includes children enrolled in standalone CHIP programs to the vaccines for children program to ensure that they are able to receive COVID-19 vaccinations.

Sec. 106 – Optional coverage at no cost sharing of COVID-19 treatment and vaccines under Medicaid for uninsured individuals. Ensures that uninsured individuals whom states opt to cover through the new Medicaid eligibility pathway will be able to receive testing, treatment and immunizations for COVID-19 without cost-sharing.

Sec. 107 – Temporary increase in Medicaid Federal financial participation for telehealth services. This section, for the duration of the public health emergency, provides a 1 percent increase to the FMAP for telehealth services for state Medicaid programs that cover telehealth services to the same extent as they are required to be covered by Medicare.

Sec. 108 – Extension of full Federal medical assistance percentage to urban Indian organizations. Ensures that tribal providers, including urban Indian organizations, are able to receive 100 percent FMAP.

Sec. 109 – Medicaid coverage for citizens of Freely Associated States. Restores Medicaid eligibility to the citizens of the Freely Associated States.

Sec. 110 – Increased FMAP for medical assistance to newly eligible individuals. Allows states that expanded Medicaid after 2014 to benefit from the enhanced FMAP that was available to states that expanded in 2014.

Under the ACA, the federal government covered 100% of the cost of Medicaid expansion for 2014, 2015 & 2016; after that it dropped to 95% in 2017, then gradually further dropped to 90% starting in 2020, where it's locked in permanently. This means that the 14 states which still haven't expanded Medicaid by now would have to pay 10% of the cost out of the gate, which can still amount to hundreds of millions, if not several billion dollars per year. Sec. 110 modifies the language so that any state which newly-expands Medicaid will have the feds cover 100% of the cost for the first three years regardless of what year they start, so if Florida or Texas does so starting in January, they'd pay nothing in 2021, 2022 or 2023; 5% in 2024 and would only start paying 10% starting in 2027 (I'm not sure how this works for mid-year expansion).

Sec. 111 – Renewal of application of Medicare payment rate floor to primary care services furnished under Medicaid and inclusion of additional providers. Ensures that primary care providers are paid no less than they would be paid under Medicare for the duration of the public health emergency.

Sec. 112 – Temporary increase in Medicaid DSH allotments. Increases Medicaid disproportionate share hospital (DSH) allotments by 2.5 percent for the duration of the public health emergency.

Sec. 113 – Temporary allowance for medical assistance under Medicaid for inmates during 30-day period preceding release. Confers Medicaid eligibility on incarcerated individuals who are otherwise eligible to enroll 30 days prior to their release.

Sec. 114 – Extension of existing section 1115 demonstration projects. Authorizes the Secretary to extend expiring section 1115 demonstration waivers through 2021 so that state Medicaid programs can prioritize responding to public health emergency.

Section 1115 of the ACA allows states to modify some aspects of how they run their Medicaid program for a limited time period with federal approval. This is an existing provision; it sounds like Sec. 114 just makes it easier to have existing 115 waivers renewed without having to go through the full reapproval process, which I assume is normally more complicated.

Sec. 115 - Preventing Medicaid disproportionate share hospital (DSH) cuts. Cancels the Medicaid DSH cuts for fiscal year 2020, and reduces the DSH cuts for fiscal year 2021 to $4 billion. It also delays the start of the fiscal year 2021 cuts until December 1, 2020.

Sec. 116 - Extension of money follows the person rebalancing demonstration. This section fully finds money follows the person for fiscal year 2020 and provides $75 million for the first two months of fiscal year 2021.

Sec. 117 - Extension of protections for Medicaid recipients of home and community-based services against spousal impoverishment. This section ensures that protections against spousal impoverishment continue to apply to spouses of recipients of home- and community-based services through November 30, 2020.

Sec. 118 - Extension of the community mental health services demonstration program. This section extends the community mental health services demonstration until November 30, 2020.

TITLE II – MEDICARE

Sec. 201 – Coverage of the COVID-19 vaccine under the Medicare program without any cost-sharing. Provides for coverage of the COVID-19 vaccine and its administration under Medicare at no out of-pocket cost to patients under Medicare Part B when such a vaccine is available. The payment amount under part B for the administration of the COVID-19 vaccine will be the same as would be allocated for the administration of a flu vaccine.

Sec. 202 – Holding Medicare beneficiaries harmless for specified COVID-19 treatment services furnished under Part A or Part B of the Medicare program. Establishes zero costsharing (out-of-pocket costs) for COVID-19 treatment under Medicare Parts A and B.

Sec. 203 – Medicare sequester delay. Places a moratorium on the two percent Medicare sequester beginning on May 1, 2020, for the duration of the COVID-19 emergency period.

Sec. 204 – Enhancing Medicare telehealth services for federally qualified health centers and rural health clinics during the emergency period. Allows Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to be paid for furnishing telehealth services to beneficiaries in their home or other setting during the COVID-19 emergency period. Medicare would pay for these services at a rate similar to the national average payment rates for comparable telehealth services under the Physician Fee Schedule.

Sec. 205 – Guaranteed issue of certain Medigap policies. Adds guaranteed issue protections for beneficiaries enrolling in supplemental Medigap plans to prevent insurance companies from denying coverage based on pre-existing conditions or health status.

Sec. 206 – Ensuring communications accessibility for residents of skilled nursing facilities during the COVID-19 emergency period. Ensures skilled nursing facilities provide a means for residents to conduct “televisitation” with loved ones while in-person visits are not possible during the COVID-19 emergency period.

Sec. 207 – Medicare hospital inpatient prospective payment system add-on payment for COVID-19 patients during the emergency period. Provides an outlier payment for inpatient claims for any amount over the traditional Medicare payment to cover excess costs hospitals incur for more expensive COVID-19 patients.

Sec. 208 – Coverage of treatments for COVID–19 at no cost sharing under the Medicare Advantage program. Establishes zero cost-sharing (out-of-pocket costs) for COVID-19 treatment under Medicare Advantage.

Sec. 209 – Establishing a risk corridor program for Medicare Advantage plans during the COVID-19 emergency. Establishes a risk corridor programs to help mitigate potential increased cost of claims experienced by Medicare Advantage plans as a result of the COVID-19 emergency.

Sec. 210 – Requiring coverage under Medicare PDPs and MA-PD plans, without the imposition of cost sharing or utilization management requirements, of drugs intended to treat COVID-19 during certain emergencies. Requires Part D prescription drug plans (PDPs) to include on their formularies any outpatient drug that has been authorized, approved, or licensed to treat COVID-19. In addition, this legislation will make clear that Part D plans may not require any copayments, coinsurance, or out-of-pocket costs for this treatment or use prior authorization, step therapy, or any other utilization management tools before covering this therapy. This provision will be in effect for the duration of the plan year of the public health emergency.

Sec. 211 – Requiring Medicare PDPs and MA–PD plans to allow during the COVID-19 emergency period for fills and refills of covered part D drugs for up to a 3-month supply. Requires Part D PDPs to allow beneficiaries to obtain up to three-month supply of their Part D prescription drugs during the COVID-19 public health emergency. This provision will be in effect for the duration of the COVID-19 public health emergency.

Sec. 212 – Extension of the work geographic index floor under the Medicare program. Extends the work Geographic Pricing Cost Index (GPCI) 1.0 floor for Medicare physician payments through November 30, 2020.

Sec. 213 – Extension of funding for quality measure endorsement, input, and selection. Extends funding for quality measure endorsement, input, and selection through November 30, 2020.

Sec. 214 – Extension of funding outreach and assistance for low-income programs. Extends funding for outreach and assistance for low-income programs (State Health Insurance Assistance Programs, Area Agencies on Aging, the National Center for Benefits and Outreach Enrollment, and the Aging and Disability Resource Centers) through November 30, 2020.

TITLE III – PRIVATE INSURANCE

Sec. 301 – Special enrollment period through exchanges; federal exchange outreach and educational activities. Provides for a two-month open enrollment period to allow individuals who are uninsured, for whatever reason, to enroll in coverage. Currently, Americans can only enroll in an ACA plan during open enrollment period, or because of a qualifying life event if they were previously insured. This package would establish a one-time special enrollment for the ACA Marketplace. allowing Americans who are uninsured to get insured in the face of COVID19, and, if eligible, have premium tax credits help make premiums affordable.

As I've been writing about for the past two weeks, every state-based ACA exchange except for Idaho has already launched a COVID-19-specific Special Enrollment Period, and I've heard from multiple sources that CMS was already planning on announcing one for the federal exchange (HealthCare.Gov) as well...but that hasn't happened as of yet. This section would require them to do so. Of course, if they announce one this week it would become moot (unless it lasts less than 2 months).

Sec. 302 – Short term limited duration insurance rule prohibition. Prohibits the relevant Secretaries from implementing, enforcing, or in any way give effect to a final rule by the Department of Health and Human Services, the Department of Treasury, and the Department of Labor that expanded short-term, limited-duration health insurance plans.

This is a duplication of H.R. 1010, which was already passed by the House last May as part of the H.R. 987 package; of course it went nowhere in the Senate last year. It would effectively reverse Trump's expansion of #ShortAssPlans, returning them to Obama-era status: They'd be restricted to no longer than 90 days and couldn't be renewed within the same calendar year...in other words, they'd go back to being both short-term and of limited duration, which is what they're supposed to be in the first place.

Sec. 303 – Rapid coverage of preventative services and vaccines for COVID-19. Requires individual and group health plans to cover any preventative vaccine and any drugs to treat COVID-19 at zero cost-sharing within 15 days of receiving an “A” or “B” rating by United States Preventive Services Task Force (USPSTF) or a recommendation from the Advisory Committee on Immunization Practices (ACIP).

The ACA already requires any immunization which receives an A or B rating from USPSTF to be covered at no cost...but it could theoretically take up to a year for this to happen. Sec. 303 requires any COVID-19 vaccine to be covered at no cost to the enrollee within 15 days.

Sec. 304 – Coverage of COVID-19 related treatment at no cost sharing. Waives cost-sharing for patients’ treatment related to COVID-19 who are enrolled in private insurance coverage. The Federal government is required to reimburse insurers for the forgone cost-sharing.

Sec. 305 – Requiring prescription drug refill notifications during emergencies. Requires group health plans and health insurance issuers offering group or individual health insurance coverage to notify patients if their plan permits advance prescription drug refills pursuant to public health preparedness guidelines or recommendations issued by the Center for Disease Control and Prevention (CDC) and provide patients with options for receiving an advance drug refill.

Sec. 306 – Improvement of certain notifications provided to qualified beneficiaries by group health plans in the case of qualifying events. Improves the information provided to workers who lose their employer-sponsored coverage so that they are aware of all affordable coverage options, including coverage available under the ACA.

If you lose your current ACA-compliant healthcare coverage (whether via your employer or otherwise), you're automatically eligible for a Special Enrollment Period...but a lot of people don't know that, and with the flood of layoffs and firings which are happening even as I type this, it's gonna be vital to let folks know that they're eligible.

Sec. 307 – Subsidies for COBRA. Provides subsidies to allow workers to maintain their employer-sponsored coverage if they become eligible for COBRA or are subject to a temporary furlough.

ACA exchange plans are a great alternative for lower-income folks, but higher-income people with employer coverage may prefer to keep their existing policies via COBRA. This would help them pay for those instead. I haven't read the details yet about how generous these subsidies would be or how long they'd last.

Sec. 308 – Risk corridor program. Establishes a two-year risk corridors program to provide payments to individual and small group market plans for extreme losses and help mitigate premium increases for consumers.

The great irony here is that this would temporarily restore one of the ACA's original stabilization programs which was put in place for the first three years of Open Enrollment (2014 - 2016)...and which was then torpedoed after Congressional Republicans insisted on calling it an "insurance company bailout". And yes, the federal government may end up having to pay out the money owed anyway, which totals some $12 billion.

Sec. 309 – Coverage of in vitro diagnostic products. Clarifies coverage requirements for in vitro diagnostic tests in compliance with the Food and Drug Administration’s (FDA) guidance on diagnostic tests for COVID-19 during a public health emergency.

Sec. 310 – Sense of Congress Regarding Surprise Medical Bills. Sense of Congress that during the COVID-19 pandemic health care providers should refrain from balance billing consumers for out-of-network claims related to COVID-19 testing or treatment, and insurance companies should do their utmost to secure access to in-network treatment for their plan participants.

I have no idea what a "Sense of Congress" provision actually does. My guess is...absolutely nothing whatsoever beyond waggling their finger at healthcare providers and insurance companies.

There's also a whole other section under "Division T" which also includes the two ACA-specific provisions I already wrote about last night:

TITLE I – Health-Related Tax Relief

Sec. 101. Payroll Tax Credit for COVID-19 Charity Care Provided by Hospitals. Our hospitals face an acute challenge during this crisis, taking on the responsibility of addressing an overwhelming increase in demand for services, regardless of a patient’s ability to pay. This provision would alleviate some of the financial strain on hospitals that treat COVID-19-affected patients by providing them a substantial tax credit to offset the charity care they provide. More specifically, the credit would be an amount equal to 90 percent of the COVID-related charity care furnished by a hospital in 2020. Finally, eligible hospitals would be able to claim this credit against their quarterly payroll taxes, with any excess credits being refundable. The credit applies to charity care furnished after January 31, 2020 through December 31, 2020. The amount of the credit would be taken into account for future Medicare DSH payments relating to hospital cost reporting periods occurring in 2020.

Sec. 102. Payroll Tax Credit for COVID-19 Hospital Facility Expenditures. Similarly, to meet the increased demand for COVID-19 testing and treatment, hospitals will need to acquire necessary equipment, beds, and, in some circumstances, retrofit or build temporary structures to treat and house affected patients. This provision would assist hospitals by offsetting the cost of “scaling up” their resources in order to care for COVID-19-affected patients. More specifically, the credit would be an amount equal to 90 percent of an eligible hospital’s capital expenditures in 2020 related to the purchase or construction of a temporary structure, the lease of a structure, or the retrofitting of any existing structure, and any depreciable property used in those structures to 57 treat affected patients. Eligible hospitals would be able to claim this credit against their payroll taxes, with any excess credits being refundable. The credit applies to expenditures paid or incurred after January 31, 2020 through December 31, 2020.

Sec. 103. Help Families Whose Incomes Are Fluctuating Not Pay ACA Penalties. People who lose their jobs or have reduced hours may have trouble predicting their annual income. Under the ACA, families must predict their incomes and pay tax credits based on their predictions. The ACA had protections for families that guessed their incomes incorrectly, and the Republicans have since stripped these protections. This provision would reinstate the protections that were in the ACA for families with fluctuating incomes to prevent these families from paying large penalties.

Sec. 104. Improving Affordability by Reducing Premium Costs for Consumers. Democrats have long prioritized getting Americans insured and providing access affordable health care, particularly in light of the health care costs Americans face with COVID-19 and economic uncertainty. This provision increases affordability by expanding eligibility for the ACA’s premium tax credits beyond the current 400 percent of the federal poverty level (FPL), and increases the size of the tax credits for individuals and families below 400 percent of FPL. These actions would increase the number of Americans with health insurance while lowering premiums for millions of middle-class Americans.

In other words, Section 104 would indeed #KillTheCliff.