Health Reform Weekly

A weekly compilation from Aetna of health care-related developments in Washington, D.C. and state legislatures across the country.


Week of December 15, 2014

According to a Commonwealth Fund survey published in Health Affairs, Americans 65 and older face significant lapses and problems in health care compared to the elderly in other industrialized nations. The results are somewhat surprising since Americans over 65 are the one segment of the population with nearly universal coverage. But the survey found that older Americans are sicker than in other industrialized nations. In fact, the U.S, leads the list when it comes to people over 65 having two or more chronic diseases. Also, older Americans still struggle to pay for health care. Nineteen percent reported that cost was a barrier to seeing a doctor, getting a procedure done or filling a prescription. The next highest rate at which the same issue was reported was 10 percent in New Zealand. Americans, however, fare better when it comes to the time doctors spend with patients and in the percentage of elderly who do advance care planning.


The House of Representatives passed a $1 trillion spending measure last week to keep the government funded through September of 2015. The bill narrowly passed the House 219-206, with 162 Republicans and 57 Democrats supporting the measure. The bill includes provisions for the health care sector, including stipulations on risk corridor funding, reconciliation of ACA tax credits, and relief for expatriate health plans, among others. The Senate also approved the bill, and President Obama signed it into law this week.

CMS has announced the process for rebidding contracts under Round Two of the Medicare durable medical equipment and supplies competitive bidding program. The bidding window will run from January 22 to March 25, with implementation of the new contracts and prices taking place July 1, 2016.


CALIFORNIA: Covered California, the state-based insurance exchange, released updated open enrollment numbers showing more than 290,000 new applications have been submitted and deemed eligible for either private health insurance or Medicaid. Covered California shared the following data: 48,952 Covered California plan selections were made and 81,287 eligibility determinations processed through Dec. 3. Also, 116,262 enrollments were processed for Medicaid coverage, with 44,295 determined to likely be eligible. In 2014 so far, Medicaid has enrolled more than 2.2 million consumers.

California legislators recently passed a new law that requires parents to have a “personal belief” form signed by their doctor if they chose not to have their children immunized. The form states that the physician has informed the parents of the risks and benefits of vaccinations, and the parents have chosen not to vaccinate their children. The form includes a clause to opt out due to religious beliefs. Since the implementation of the form, more California kindergarteners received immunizations before starting school this year than in the previous decade. California is now experiencing one of its worst whooping-cough outbreaks in years, which health experts are tying to years of low vaccination rates. According to the California Department of Public Health, 13,260 parents filed a personal belief form for the 2014-2015 school year, a 20 percent drop compared to the 2013-2014 school year.

COLORADO: A Connect for Health Colorado (state-based exchange) audit has found financial mismanagement and possible illegal payments for lobbying. Bipartisan members of the Legislative Audit Committee voted unanimously last week to conduct a comprehensive exchange audit in 2015. The proposed legislation will mirror a bill that passed Colorado’s House earlier this year with support from all but one lawmaker. The legislation was killed in the Senate after lobbying from Connect for Health’s former CEO.

CONNECTICUT: A week after the Attorney General and the Office of Healthcare Access (OHA) tentatively approved the Tenet’s acquisition of Waterbury Hospital with conditions, Tenet announced that it is withdrawing its applications for Waterbury Hospital and four other hospitals in the state. Reportedly, the conditions most problematic to Tenet are that once acquired the hospital can’t reduce or move any existing inpatient or outpatient services for five years nor can the clinical workforce fall below a certain level for five years. Attorney General George Jepsen issued the following statement following Tenet’s announcement: “This decision raises substantial and immediate questions about the future of health care delivery in some of our communities. Those questions deserve the closest attention of policymakers at the local and state levels.”

FLORIDA: The Florida Health Insurance Advisory Board voted last week in favor of several recommendations to streamline state laws that are now inconsistent with new federal requirements. Composed of health insurers, brokers and advocates, the board was created by statute, and the Commissioner of Insurance serves as the Chair. Aetna participates on the board.

ILLINOIS: As the Illinois legislature finished its business before adjourning for 2014, some lawmakers and the Governor’s office pushed for enactment of a measure to create a state-based insurance exchange. Illinois currently operates a partnership exchange, and some policymakers were concerned that residents may not be eligible for coverage subsidies through the state’s current exchange if the U.S. Supreme Court rules that only individuals on state-based exchanges are eligible to receive federal subsidies. The Court recently agreed to hear a case challenging the legality of consumer subsidies provided through federal exchanges. Also, applications for federal grant money to assist with establishing state-based exchanges must be filed by December 31, 2014. Despite a concerted effort by proponents of the state-based exchange, the legislature did adjourn without enacting such a measure. It is not clear whether state-based exchange proponents will attempt to move legislation again in January of 2015.

NEW HAMPSHIRE: The state’s Network Adequacy Working Group has shared proposed changes to the state’s existing network adequacy process. One change would shift the process toward measuring access to care within insurance networks by counting the types of medical services people use, as opposed to their medical providers. Regulators noted that their objective is to allow for networks that are based on cost-effective health care, including from non-traditional providers and settings. While the new standards remain under development, the goal is to apply them to insurance products offered in 2017.

The Department’s proposed draft model would break down services into four categories: core services (including primary care, mental health and substance abuse treatment), common services (including general surgery, rehabilitation and vision care), specialized services (including heart surgery, oncology and neurological services) and highly specialized services (including transplants and other complex surgical procedures). In terms of accessibility, core services would be those accessible within the department’s definition of a “community,” while more specialized services would perhaps be accessed across state lines. The new standards would take into account telemedicine and other new approaches to medical care.

NEW YORK: Governor Andrew Cuomo last week announced a state policy directive to all health insurers requiring coverage for the treatment of gender dysphoria. New York becomes the ninth state to extend health insurance protections to transgender individuals. The directive emphasizes that insureds are to be afforded the full range of utilization review appeal rights. The policy directive notes that the Diagnostic and Statistical Manual (DSM) used by mental health professionals recognizes a diagnosis of gender dysphoria. As a result, an insurer is required to include the condition in its definition of mental health conditions, entitling persons with gender dysphoria to the protections of federal mental health parity and New York’s Timothy’s Law.

OREGON: The Oregon Insurance Department has released open enrollment numbers that show more than 19,000 Oregonians have enrolled in private health care coverage through the federally facilitated marketplace as of November 30. Following months of effort to fix its troubled website, Cover Oregon’s board decided earlier this year to begin using rather than continue to try to repair the existing exchange website. The state retains some functions while is utilized to enroll people in private plans and Medicaid through the exchange.

TEXAS: Commissioner Julia Rathgeber will be stepping down from the Texas Department of Insurance to become Governor-elect Abbott’s Deputy Chief of Staff. Nothing has been announced yet concerning the naming of an interim commissioner. However, the Texas legislature will need to confirm a new commissioner by the time it adjourns in May.

VIRGINIA: The Department of Health facilitated a meeting last week with HIV/AIDS stakeholders that focused on exchange enrollment and efforts made to date to ensure the stability of the program. The meeting included representatives from the Health Department, Virginia Organizations Responding to AIDS (VORA), multiple pharmaceutical companies, hospital systems, advocates and the Virginia Association of Health Plans. Aetna State Government Affairs attended the meeting as well. Though no concrete decisions were made nor objectives agreed to, all of the stakeholders agreed to continue to meet and find ways to provide health care providers and enrollees in the Commonwealth’s AIDS Drug Assistance Program (ADAP) better information about how health insurance works and how to access benefits. The group will meet again in March after the 2015 Legislative session adjourns.


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