ࡱ> q` qbjbjqPqP 7::hgZZZZZZZn6U6U6U8nUlU n?LVV"WWWWWW$hZZWWZZZZWW\\\Z|ZWZW\Z\\jҚZZRWV *DG6UZf2 0?w$[*wdRR8wZWL;X6\qX,XwWWWN\XWWW?ZZZZnnn,R2"nnnR2nnnZZZZZZ SENATE HELP BILL (as of July 2, 2009) **Medicaid is under the jurisdiction of the Finance Committee. In the updated HELP bill released on 7/1, the Medicaid assumption portions of the bill were removed. **SENATE FINANCE PROPOSAL (as of October 5, 2009) HOUSE DEMOCRAT ENERGY & COMMERCE COMMITTEE PROPOSAL (as of September 26, 2009)  Medicaid and CHIP Eligibility Levels/ Expansion  Beginning in 2014, expands Medicaid income eligibility levels to parents and children six and older who fall at or under 133% of the poverty line. Non-elderly non-pregnant individuals (childless adults) making up to 133% of poverty would also be eligible for the first time. Requires states to maintain Medicaid and CHIP eligibility levels until 2013 for those with incomes above 133% FPL and until 2014 for those with incomes at or below 133% FPL. A state is exempt from the maintenance of effort requirement for non-disabled adults with incomes above 133% FPL between January 2011 and January 2013 if the state certifies that it is experiencing a budget deficit or will experience a deficit in the following year. Effective January 1, 2014, income disregards would no longer apply for Medicaid or CHIP, and income would be measured based on modified adjusted gross income (MAGI). An exception to this rule would be made for those groups that are eligible for Medicaid through another program (i.e., foster children). After September 30, 2013, establishes a Federal floor for CHIP eligibility at 250 percent of FPL requiring states to offer CHIP to all children between 134 and 250 percent of FPL. Creates a state option for a government-sponsored basic health plan to provide coverage to individuals below 200% of the federal poverty level. This was added through an amendment by Sen. Cantwell (D-WA) which was modeled after the current Basic Health plan in Washington in which Molina Healthcare Washington participates. In Medicaid, increased federal financing (100% in 2013-2014; 90% beginning in 2015) for: non-disabled, childless adults up to 133% FPL (whether previously covered through a waiver or not); traditional populations between a states current income threshold and 133% FPL (including children shifted from CHIP); and uninsured newborns for first 60 days. States currently covering parents through waivers receive the increased federal financing between non-waiver eligibility standard and 133% FPL. MOE populations above 133% FPL receive regular federal match. States will be required to maintain levels of eligibility for current Medicaid and CHIP beneficiaries. Requires State Medicaid programs to enter into a memorandum of understanding with the Health Choices Commissioner to coordinate enrollment of low-income individuals into the Exchange or Medicaid as appropriate. Requires stand-alone CHIP programs to provide 12-month continuous eligibility for all enrollees with incomes below 200% FPL. Enrollment and RenewalA Gateway shall implement policies and procedures to facilitate the identification of individuals who lack qualifying coverage and assist them in enrolling in Medicaid or CHIP.Effective 2014, all hospitals that participate in Medicaid can make presumptive eligibility determinations, in addition to providers currently able to do so. Creates a single streamlined, national application form for Medicaid, CHIP, and tax credits that would be accepted by Internet, mail, fax, or in person (Rockefeller amendment).Beginning in 2013, states must eliminate any asset test used to determine eligibility for children, parents, and many childless adults (long term care and disability populations exempted) in Medicaid. Requires automatic enrollment in Medicaid for an exchange-eligible individual who is eligible for Medicaid. Stand-alone CHIP programs will be required, effective January 1, 2010, to implement 12-month continuous eligibility until the program expires. States cannot have enrollment waiting periods for children in CHIP who are: under age 2, have lost employer health insurance, or have access only to unaffordable coverage in which costs exceed 10% of family income. (In effect 90 days after bills enactment until program expires.)Health Insurance ExchangeIndividuals eligible for Medicaid will be covered through state Medicaid programs. Individuals eligible for CHIP have the option of enrolling in CHIP or enrolling in a qualified health plan through the Gateway. A Gateway shall implement policies and procedures to facilitate the identification of individuals who lack qualifying coverage and assist them in enrolling in Medicaid or CHIP.Non-elderly, non-pregnant adults between 100% and 133% FPL would be able to choose between Medicaid and coverage through their state exchange. States would have to ensure that all children of parents who choose the state exchange coverage would continue to receive the benefits, including EPSDT benefits, to which children are entitled under Medicaid. For any non-elderly, non-pregnant adult between 100 and 133 percent of FPL who chooses the state exchange in place of Medicaid, states would be required to pay an amount equal to the states average cost of coverage for individuals in that same Medicaid eligibility category. Requires states to establish a Medicaid enrollment website to promote seamless enrollment in Medicaid should a Medicaid eligible individual apply for tax credits through a state exchange website or vice versa. Keeps low-income children in CHIP instead of covering them through the Exchanges.Requires states to maintain current income eligibility levels for children in CHIP until 2019. Beginning in 2014, states will receive a 23 percentage point increase in the CHIP match rate up to a cap of 100% and a .15 percentage point increase in the Medicaid match rate. CHIP-eligible children who are unable to enroll in the program due to enrollment caps will be eligible for tax credits in the state exchanges. (Passed by amendment offered by Sen. Rockefeller)Medicaid-eligible individuals will generally be enrolled in Medicaid, not the Exchange. An exception is made for childless adults with incomes under 133% of poverty who had other qualifying coverage within the previous six months. They have the choice to obtain coverage through Medicaid or the Exchange. There would be a maintenance-of-effort requirement for CHIP through 2013. Maintenance of effort ends with the opening of the Health Insurance Exchange in 2013 or, if later. People eligible for Medicaid could not receive subsidies via an exchange. Requires the Commissioner to enter into memorandums of understanding with state Medicaid agencies to coordinate enrollment in Medicaid and the Exchange for Medicaid-eligible individuals. Requires the Commissioner to study access to insurance and benefits to determine if those eligible for employer-sponsored insurance or Medicaid should be made eligible to receive affordability credits in the future. Requires that CHIP enrollees not be enrolled in an Exchange plan until the Secretary certifies that coverage is at least comparable to coverage under an average CHIP plan in effect in 2011. The Secretary must also determine that there are procedures to transfer CHIP enrollees into the exchange without interrupting coverage or with a written plan of treatment. For subsidy purposes, a childs family income is deemed to be no greater than was determined for CHIP. FMAP IncreaseBeginning in 2014, the Federal government would pay a greater share of the costs for individuals newly eligible for Medicaid based on the proposed eligibility changes. Those states that offer minimal or no coverage of the newly-eligible population currently would receive more assistance initially than those states that currently cover at least some non-elderly, non-pregnant individuals. Such coverage may be less comprehensive than Medicaid, but must be more than premium assistance, hospital-only benefits, or health savings accounts (HSA). Between 2014 and 2018, the additional assistance to expansion states and other states would be adjusted downward and upward, respectively, so that, in 2019, all states would receive the same level of additional assistance for covering newly eligibles. The additional assistance would be provided through a percentage point increase in FMAP, according to a specific schedule. The FMAP could not exceed 95 percent in any year as a result of the schedule above. Requires GAO to conduct reports on Medicaid FMAP formula and Medicaid administrative costs. Medicaid Provider Payment RatesMedicaid payments to primary care physicians and practitioners for primary care services are increased from 80% of Medicare rates in 2010, to 90% in 2011, and 100% in 2012. New costs associated with rate increases will be fully funded by federal government until 2015 at which point the federal government will pay 90% of additional costs.  Waste, Fraud and AbuseIncreases processes to eliminate fraud and abuse in all health care services and programs.States are given the authority to impose screening procedures in Medicaid, including subjecting providers and suppliers to enhanced oversight and establishing new disclosure requirements. States would be authorized to deny participation to providers and suppliers that do not follow the screening procedures. States failing to create effective screening programs would be subjected to a financial penalty through a reduction in FMAP. Existing provider databases would be expanded and consolidated with a national patient abuse/neglect registry into a centralized sanctions data system. Requires CMS to complete development of the comprehensive One PI Integrated Data Repository (IDR). The One PI IDR would expand existing program integrity data sources and expand data sharing and data matching across Federal health care claims and payment data. Medicare and Medicaid providers and suppliers would be required to implement compliance programs as a Condition of Participation. Extends the RAC program to Medicare Parts C and D and Medicaid.Require providers and suppliers to adopt compliance programs as a condition for participating in Medicare and Medicaid. Requires Medicaid Integrity Program contractors to submit to the Secretary an annual report on integrity activities. Requires providers and suppliers participating in Medicaid (other than physicians and nursing facilities) to establish compliance programs. Effective 2011, requires State Medicaid and CHIP programs to terminate the participation of entities or individuals if the entity or individual is terminated under Medicare, any other state Medicaid program, or any other CHIP program. Effective 2011, requires State Medicaid and CHIP programs to exclude individuals or entities from participation if the individual or entity owns, controls, or manages an entity has unpaid overpayments or is suspended or excluded from participation. Requires State Medicaid programs to include in their Management Information Systems reports to the Secretary data elements necessary for the detection of waste, fraud, and abuse. Effective 2012, requires agents, clearinghouses, or another alternate payees that submit claims on behalf of a health care provider to register with the State and the Secretary. Denies payment for any claims submitted by an unregistered alternate payee. Effective January 1, 2012. Prohibits federal matching payments for costs in litigation costs in which a court imposes sanctions for litigation-related misconduct.  Long- Term CareEstablishes a national voluntary LTC insurance program (CLASS program) to provide cash benefits, advocacy services, and counseling for individuals with disabilities. For institutionalized Medicaid beneficiaries, they would retain 5% of the daily or weekly cash benefit and the remainder would be applied towards the institutions cost of providing care. Medicaid would provide secondary coverage for such care. For Medicaid beneficiaries receiving home and community-based services, they would retain 50% of the daily or weekly cash benefit and the remainder would be applied toward the cost to the state of provide such assistance. Medicaid would provide secondary coverage for the remainder of any costs incurred. Extends the Money Follows the Person Rebalancing Demonstration through September 30, 2016. Health Care QualityEstablishes uniform categories for collecting data on race and ethnicity, gender and primary language. The OMB Directive 15 standards and the OMB policy for aggregation and allocation of subgroups for race and ethnicity data would be applied to Medicaid. CMS would be required to collect primary language data on CHIP enrollees and their parents. Directs HHS, in consultation with the states, to develop an initial set of health care quality measures specific to adults who are eligible for Medicaid. Establishes the Medicaid Quality Measurement Program which would expand upon existing quality measures, identify gaps in current quality measurement, establish priorities for the development and advancement of quality measures and consult with relevant stakeholders. States would receive grant funding to support the development and reporting of quality measures. Prohibits Federal payments to states for Medicaid services related to health care acquired conditions. Creates a demonstration project to evaluate bundled payments for acute and post-acute services, and/or concurrent physician services in up to 8 states. Authorizes $11 million for MACPAC for FY2010. Expands MACPACs mission to include assessment of adult services in Medicaid, including for dual eligibles, and more detailed reporting requirements to states and Congress.In Medicaid, establishes a medical home pilot program for high-need beneficiaries. Creates a pilot program in Medicaid to establish Accountable Care Organizations, a group of providers responsible for the quality and cost of health care for beneficiaries. Requires the Secretary to develop quality measures for maternity care provided under Medicaid and SCHIP by July 1, 2011. The Secretary is required to develop a standardized reporting format for MCOs and providers by Jan 1, 2012. The amendment further requires the development of other quality measures for adult care in Medicaid not already developed to the extent they provide insight into the quality of services provided in Medicaid. The Secretary is required to report to Congress annually on the availability of data on the quality of maternity and adult services provided in Medicaid and CHIP, and recommendations on improving the quality of services provided in Medicaid and CHIP. Prevention and WellnessStates that provides Medicaid coverage for all recommended preventive services and immunizations and removes cost-sharing for these services would receive a 1% increase in the federal share of its FMAP for those services. States would be required to provide Medicaid coverage for tobacco cessation services for pregnant women without cost-sharing. Allows states to design a proposal and apply for funds to provide incentives to Medicaid enrollees who improve their health status and complete scientifically-based healthy lifestyle programs. Creates a new Medicaid state plan option under which Medicaid enrollees with at least two chronic conditions or with one chronic condition and at risk of developing another chronic condition, could designate a provider as their health home.Current Medicaid benefit rules maintained with addition of mandatory coverage of preventive services for adults (no cost-sharing allowed and funded through regular federal matching rate). Requires coverage of tobacco cessation counseling for pregnant women. Prescription DrugsRequires manufacturers to pay rebates to State Medicaid programs for drugs dispensed to program beneficiaries enrolled in Medicaid managed care organizations. Would not prohibit MCOs from negotiating with manufacturers and wholesalers for rebates above Medicaids statutory rebates. Makes prescription drugs a mandatory benefit for the categorically and medically needy, effective January 1, 2014. Removes smoking cessation drugs, barbiturates, and benzodiazepines from Medicaids excluded drug list, effective January 1, 2014. Increases the flat rebate percentage used to calculate Medicaids basic rebate for outpatient brand name prescription drugs to 23.1%. Increases the rebate for non-innovator, multiple source drugs to 13% of AMP. Increases the minimum rebate amount on brand name drugs to 22.1% Requires manufacturers to pay rebates to State Medicaid programs for drugs dispensed to program beneficiaries enrolled in Medicaid managed care organizations. Extends current rules for Medicaid payments to pharmacists for multiple source drugs through December 31, 2010. Thereafter, limits Medicaid payments for such drugs to 130% of the weighted average manufacturer price (AMP). Redefines AMP to exclude certain price concessions, including those provided to pharmacy benefit managers, not passed through to retail pharmacies.Medical Cost Ratio RequirementsA health insurance issuer offering group or individual health insurance coverage shall publicly report (in a manner to be established by the Secretary through regulation) the percentage of total premium revenue that such coverage expends: 1) on reimbursement of clinical services provided to enrollees under such plan or coverage; 2) for activities that improve health care quality; and on all other non-claims costs, including an explanation of the nature of such costs. Beginning in 2010, health plans would be required to report the proportion of premium dollars that are spent on items other than medical care. Requires Medicaid managed care organizations to have a minimum medical loss ratio of at least 85%. This shall apply to contracts entered into or renewed on or after July 1, 2010. Extends MLR provisions to CHIP plans. This provision shall apply to contracts entered into or renewed on or after July 1, 2010.  Dual Eligibles/ Special Needs Plans Creates an office or program within CMS to improve coordination between Medicare and Medicaid for all duals. Extends the SNP program for 3 years. Requires Secretary to transition non-qualified beneficiaries from SNPs to other MA plans or original Medicare by 2013. Requires all dual-eligible SNPs to have established contracts with state Medicaid programs by January 1, 2013. Make all changes related to payment, rebates and bonuses, as well as payment and service areas apply to SNPs in the same manner as they apply to MA plans through 2013. Dual SNPs are prohibited from charging premiums if their bids exceed benchmark. Gives Secretary authority to pay fully integrated SNPs frailty adjuster if they have similar risk levels to PACE and if they provide long-term care services. Beginning in 2012, SNPs must be certified by the National Committee for Quality Assurance (NCQA). Beginning in 2011, the Secretary would use a risk score for new enrollees in SNPs that reflects the known underlying risk profile and chronic health status of each enrollee. Extends the SNP program through 2012, and extends certain fully integrated dual eligible SNPs (WI, MA, MN) through 2015. Creates an office or program within CMS to improve coordination between Medicare and Medicaid for all duals. Prohibits charging duals and QMBs higher cost sharing than if they were not enrolled in MA plan starting Jan. 2011. Medicare AdvantageImplements competitive bidding based on specific schedule. Includes bonus payments for plans based on their performance on quality measures and the operation of evidence-based care management programs. Plans that provide care at lower costs than traditional Medicare would also be eligible for an efficiency bonus. Rebates and bonuses paid to MA plans would need to be used to provide additional benefits that are not covered under Medicare. Limits cost sharing for certain services, like chemotherapy and skilled nursing care. Plans would still be allowed to offer supplemental benefits for which they would charge beneficiaries an added premium, as under current law. Requires bid information submitted by MA plans to be certified by a member of the American Academy of Actuaries. Shifts the annual enrollment period dates for Medicare Advantage and Part D to October 15 to December 7.Reduces Medicare Advantage benchmarks to fee-for-service levels over three years, reaching equality of payment rates in 2013. Includes bonuses for quality. Extends CMS authority to adjust risk scores in Medicare Advantage for observed differences in coding patterns relative to fee-for-service. Eliminates the MA Regional Plan Stabilization Fund. Beginning in 2011, requires CMS to publish standardized information on medical loss ratios and other plan information to beneficiaries and the public. For plans with medical loss ratios below 85%, requires rebates and increasing penalties over time, including eventual termination of contracts. Restricts the ability of Medicare Advantage plans to offer coverage outside their service area and grandfathers current contracts. Requires a study on the effectiveness of the MA risk adjustment system for low-income and chronically ill populations. Requires CMS to improve the risk adjustment system taking into account results from the study. Ensures that beneficiaries in MA plans are not subjected to higher cost-sharing than they would face in fee-for-service Medicare. Clarifies that CMS is not obligated to accept any or every bid submitted by a Medicare Advantage or Part D plan.Provider Tax No ProvisionNo ProvisionExtends the Medicaid MCO provider tax authority for one year until October 1, 2010. OtherAn annual fee on the health insurance sector would be set at $6 billion beginning in 2010. The aggregate fee is apportioned among the providers based on relative market share. Allows children who are eligible for Medicaid to receive hospice services without forgoing any other service to which the child is entitled under Medicaid. Imposes statutory requirements regarding transparency in the development, implementation, and evaluation of Medicaid and CHIP section 1115 demonstration programs. Imposes statutory requirements on the Secretary of HHS with respect to waivers and demonstration programs. The Secretary, among other things, would be required to publish a Federal Register notice identifying monthly waiver approvals, denials, and returns to the state without action. Identifies free-standing birthing centers as Medicaid providers. State DSH allotments would remain intact as under current law until a state trigger is tripped. The trigger would be tripped once a states uninsured rate, as measured by the Census Bureaus American Community Survey, decreases by at least 50 percent, compared to an initial uninsured rate on the date of enactment. Requires the Secretary of HHS to ensure all appropriate privacy and security safeguards are followed for activities relating to health disparities data collection, analysis, and sharing. Establishes a new state grant program for early childhood home visitation. Imposes new requirements on insurers to meet standards for the electronic exchange of payment and other health care information with hospitals, doctors and other providers. By 2014, insurers must comply with standards for certain transactions or face a penalty fee assessed annually by HHS and collected by Treasury.Requires states to submit to the Secretary provider rate-setting data that will allow the Secretary to determine compliance with equal access requirements, including data relating to how rates established for payments to Medicaid MCOs under Sections 1903(m) and 1932 take into account such payment rates. Requires the Secretary of HHS to report to Congress by January 1, 2016 on the continuing role of Medicaid Disproportionate Share Hospitals (DSH) as health reform is implemented. Reduces DSH payments to states are reduced by $10 billion from 2017-2019. Effective July 1, 2010, requires State Medicaid programs to allow adults to apply for Medicaid coverage at DSH hospitals, FQHCs, and other locations than welfare offices (requirement already applies to pregnant women and children). Allows State Medicaid programs to cover home visits by trained nurses to families with a first-time pregnant woman or child under 2 eligible for Medicaid. Allows for optional Medicaid coverage of low-income HIV-infected individuals. Sunsets on January 1, 2013. Allows State Medicaid programs to cover low-income women who are not pregnant for family planning services and supplies without obtaining a waiver. Allows State Medicaid programs to cover such services for such women during a presumptive eligibility period. Provides a 75% federal matching rate for the costs of translation or interpretation services for Medicaid-eligible adults for whom English is not the primary language. Allows State Medicaid programs to cover services provided by birth centers that are not hospitals. Allows children who do not have insurance coverage for immunizations to receive vaccines through the VFC program at a public health clinic. Extends the authorization of the Transitional Medicaid Assistance to December 31, 2012. Eliminates the funding limitation and extends through December 2012 the qualified individuals program to assist low-income Medicare beneficiaries with paying Medicare premiums. Permanently extends the required coverage of non-emergency transportation in Medicaid for medically necessary services. Requires Medicaid coverage of medical services provided by optometrists, provided they fall within the scope of services permitted under state scope of practice laws. Establishes new transparency and disclosure requirements for qualified health benefits plans. Plans would be required to comply with standards for the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment practices, and periodic financial disclosure. 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