Thursday, March 31, 2016

We are happy to announce the launch of a new video promoting the service agents and brokers provide to small businesses through the SHOP Marketplace.


This video will be promoted to small employers through email, social media, and


Thank you,

The SHOP Marketplace Team

Coverage Rate for Homeless Rose to 67% in Medicaid Expansion States

Kaiser Family Foundation recently conducted a study on the impact of the Affordable Care Act Medicaid expansion on Health Care for the Homeless (HCH) projects. Here are some key findings from the report:

·         In Medicaid expansion states, the coverage rate for the homeless rose from 45% in 2012 to 67% in 2014.

·         The coverage rate increased from 26% to 30% in non-expansion states.

·         In expansion states, total revenues for HCH projects in 2014 were 7% higher than total revenues in 2013.

·         Revenues for HCH projects in non-expansion states increased by 2%.

·         Third party payments increased to 43% of funding for HCH projects in expansion states.

·         Half (49%) of total revenue for HCH projects in expansion states came from grants in 2014.

Source: Kaiser Family Foundation, March 15, 2016

According to a recent study of the electronic logs of 3 large practices,

... primary care physicians received a mean of 76.9.electronic notifications each day, while specialists received a mean of only 29.1 notifications per day.

Source: "The Burden of Inbox Notifications in Commercial Electronic Health Records," JAMA Internal Medicine, March 14, 2016,   

According to a recent study:

  • 29% of patients with health care-associated infections were readmitted to the hospital, compared with 16.5% of those who did not develop an HAI
  • 9.3% of total bed days were linked to excess length of stay due to an HAI
  •  11.4% of total costs were due to excess length of stay
  • The 1-year overall mortality rate for patients with an HAI was 1.75, compared to all other patients

Source: "Direct health care costs and length of hospital stay related to health care-acquired infections in adult patients based on point prevalence measurements," American Journal of Infection Control, abstract only, March 14, 2016,

$470 billion ...

... was saved in Medicare between 2009 and 2014 because of a slowdown in the growth of health care spending, according to a March 22 report from HHS.

"We estimate that the 12.7 million [ACA] signups ...

... so far represent 46% of the 'potential market' for the marketplaces. The potential market includes people who are uninsured or purchasing their own coverage. It excludes those who have an employer offer of insurance, are eligible for Medicaid, are undocumented immigrants, or who have incomes below the poverty level and live in states that have not expanded Medicaid."

— From a new report by the Kaiser Family Foundation that looks at current Affordable Care Act exchange enrollment.

According to a recent study based on the National Health and Nutrition Examination Survey...

the following percentages of U.S. adults achieved any of four basic behavioral characteristics that researchers say would constitute a “healthy lifestyle”:

  • 71.5% did not smoke
  • 37.9% ate a healthy diet
  • 9.6% had a normal body fat percentage
  • 46.5% were sufficiently active
  • Only 2.7% of all adults had all four healthy lifestyle characteristics, while16% had three, 36.8% had two, 33.5% had one, and 11.1% had none

Source: "Healthy Lifestyle Characteristics and Their Joint Association With Cardiovascular Disease Biomarkers in US Adults," Mayo Clinic Proceedings, March 21, 2016,

Top Five Wearable Vendors Market Share 2015 by "Unit Shipments"

1. FitBit: 26.9% - 21.0 Million units
2. Xiaomi: 15.4% - 12.0 Million units 3. Apple: 14.9% - 11.6 Million units 4. Garmin: 4.2% - 3.3 Million units 5. Samsung: 4.0% - 3.1 Million units Others: 34.5% - 34.5 Million units

Source: IDC Worldwide Quarterly Wearable Device Tracker, February 23, 2016

2.7% of US Adults Achieve All Four Healthy Behaviors

Researchers from Oregon State University and the University of Mississippi recently conducted a study on four healthy lifestyle behaviors (good diet, moderate exercise, recommended body fat percentage, non-smoking) in U.S. adults. Here are some key findings from the report:

·         2.7% of all adults had all four healthy lifestyle characteristics, while 16% had three.

·         37% had two, 34% had one, and 11% had none of the healthy lifestyle characteristics.

·         Mexican American adults were more likely to eat a healthy diet than non-Hispanic white or black adults.

·         Women were more likely to not smoke and eat a healthy diet, but less likely to be sufficiently active.

·         1 in 10 had a normal body fat percentage and 46% were sufficiently active.

·         71% adults did not smoke and 38% ate a healthy diet.

Source: Oregon State University, March 21, 2016

Wednesday, March 30, 2016

CMS finalizes mental health and substance use disorder parity rule for Medicaid and CHIP



FOR IMMEDIATE RELEASE                                    Contact: CMS Media Relations     

March 29, 2016                                                                (202) 690-6145 | CMS Media Inquiries          



CMS finalizes mental health and substance use disorder parity rule for Medicaid and CHIP

Final rule strengthens access to mental health and substance use disorder benefits for low-income Americans


In conjunction with the President’s visit to the National Rx Drug Abuse and Heroin Summit, the Centers for Medicare & Medicaid Services (CMS) today finalized a rule to strengthen access to mental health and substance use services for people with Medicaid or Children’s Health Insurance Program (CHIP) coverage, aligning with protections already required of private health plans. The Mental Health Parity and Addiction Equity Act of 2008 generally requires that health insurance plans treat mental health and substance use disorder benefits on equal footing as medical and surgical benefits.


“The Affordable Care Act provided one of the largest expansions of mental health and substance use disorder coverage in a generation,” HHS Secretary Sylvia M. Burwell said. “Today’s rule eliminates a barrier to coverage for the millions of Americans who for too long faced a system that treated behavioral health as an unequal priority. It represents a critical step in our effort to ensure that everyone has access to the care they need.


“This rule will also increase access to evidence-based treatment to help more people get the help they need for their recovery and is critical in our comprehensive approach to addressing the serious opioid epidemic facing our nation.” 


“The need to strengthen access to mental health and substance use disorder services is clear,” said Vikki Wachino, Deputy Administrator of CMS and Director of the Center for Medicaid and CHIP Services. “This final rule will help states strengthen care delivery and support low-income individuals in accessing the services and treatment they need to be healthy.”


The protections set forth in this final rule will benefit the over 23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP. Currently, states have flexibility to provide services through a managed care delivery mechanism using entities other than Medicaid managed care organizations, such as prepaid inpatient health plans or prepaid ambulatory health plans. The final rule maintains state flexibility in this area while guaranteeing that Medicaid enrollees are able to access these important mental health and substance use services in the same manner as medical benefits.


Under the final rule, plans must disclose information on mental health and substance use disorder benefits upon request, including the criteria for determinations of medical necessity. The final rule also requires the state to disclose the reason for any denial of reimbursement or payment for services with respect to mental health and substance use disorder benefits.


This is one of our latest efforts to increase access to and improve mental health services and care for low income individuals, especially in light of the opioid abuse epidemic, which constitute significant health risks and cost drivers in the Medicaid program. We introduced several initiatives to assist states with behavioral health system transformation to better meet the needs of beneficiaries with substance use disorders: 


  • In 2014, CMS launched the Innovation Accelerator Program, a new strategic and technical support platform designed to improve delivery systems for beneficiaries that are high need and high cost. Our first effort in this area was to provide states with expert resources, coaching opportunities and individualized technical assistance to accelerate policy, program and payment reforms appropriate for a robust substance use disorder delivery system.


  • In July 2015, CMS issued guidance to states on a new section 1115 demonstration opportunity to develop a full continuum of care for beneficiaries with a substance use disorder, including coverage for short-term residential treatment services not otherwise covered by Medicaid.


  • In response to the growing prescription opioid abuse epidemic, CMS recently released information on effective safeguards and options to help address over-prescribing of opioid pain medications.


  • CMS disseminated important information regarding screening and early intervention services for children and youth who have or may have a mental illness or substance use disorder, including best practice information for the delivery of medication-assisted treatment as well as services and supports that can address first psychiatric episodes to reduce the likelihood of ongoing hospitalizations, involvement with police and courts, and increase the chances of keeping families intact.



The final rule is currently on display at and will be published in the Federal Register on March 30, 2016.


CMS will be hosting a webinar, “Agent and Broker Tips for Assisting in the Small Business Health Options Program (SHOP) Marketplaces,”

Wednesday, April 20 from 1:00 PM to 2:30 PM Eastern Time.


CMS subject matter experts will provide tips for agents and brokers on how they can use the SHOP Marketplace effectively, including:


  • The benefits of the SHOP Marketplace for agents and brokers
  • How to access training on the SHOP Marketplace Agent/Broker Portal
  • A review of the SHOP Marketplace employer and employee applications


To register for the webinar, please log in to If you have questions on the webinar registration process, visit the “Upcoming Agent and Broker Webinars” section of the Agents and Brokers Resources webpage for more information.

50% ...

... of the 341 employers surveyed by the Pharmacy Benefit Management Institute's 2016 Trends in Specialty Drug Benefits Report have formulary exclusions for growth hormones, followed by hepatitis C (47%), fertility (43%), cholesterol (37%) and multiple sclerosis (32%).

"I think CMS [in its 2017 Benefit and Payment Parameters rule for] ...

... is trying to draw a distinction between network adequacy and narrow networks. And the two are different concepts not in conflict with one another at all. Network adequacy means that when I need a provider there is a provider available to me. And some of the literature around network adequacy has related to how far I have had to travel, whether there are all the specialists you would need in-network and am I being forced out of network to get the care I need, the personnel to serve me.... [The narrow network issue is one of choice.] It's not whether any provider is available to me, it is do I have choice among providers available to me."

— Deborah Chollet, Ph.D., fellow at Mathematica Policy Research, told AIS's Health Plan Week.

$270 billion to $550 billion ...

... over 10 years would be the cost of Donald Trump's health care plan, which would cause 21 million people to lose coverage, according to an analysis by the Committee for a Responsible Federal Budget.

Monday, March 28, 2016

58% of Part D Covered Drugs Subject to Coinsurance

Avalere recently conducted an analysis on prescription drug coverage for Medicare Part D (PDPs) and Medicare Advantage (MA-PDs) plans. Here are some key findings from the report:

·         The percentage of covered drugs facing coinsurance rose from 35% in 2014 to 58% today among PDPs.

·         24.6 million Medicare beneficiaries are currently enrolled in PDPs.

·         96% of PDP members are enrolled in plans with more than 1 tier requiring coinsurance, vs. 39% in 2014.

·         Medicare rules cap the amount of coinsurance for specialty tiers at 33% of the cost of the product.

·         The maximum cap on non-preferred brand tiers is 50%, while preferred brand tiers are capped at 25%.

·         Medicare Advantage plans currently charge coinsurance for 26% of covered drugs.

Source: Avalere, March 10, 2016

"Retail clinics have been viewed by policy makers and insurers as a mechanism ...

... to decrease health care spending, by substituting less expensive clinic visits for more expensive emergency department or physician office visits. However, retail clinics may actually increase spending if they drive new health care utilization."

— According to researchers who conducted a study published in the March issue of Health Affairs.

49% ...

... of Medicare Advantage contracts, representing 71% of plan enrollees, have achieved ratings of 4 stars or above, compared to an estimated 17% in 2009, according to CMS.

Total enrollment in Medicare Advantage and other prepaid plans increased ...

... by 28,572 to 18,232,317 as of the March 1 payment date, compared with the Feb. 1 figures, reflecting enrollments in the 28-day period ending Feb. 5 .

A report released on March 17 by the Government Accountability Office (GAO) ...

... said more than 600,000 public exchange members have had their policies discontinued due to the closure of Consumer Operated and Oriented Plans (CO-OPs). Last June, about 1 million individuals were enrolled in coverage sold by CO-OPs, but that number has since tumbled to less than 400,000 because of the many CO-OP failures, according to the report. There are now just 11 CO-OPs operating, down from the original 23. And Maine's Bureau of Insurance told CMS in a letter on March 14 that its CO-OP, the Maine Community Health Options carrier, is nearly insolvent. On March 21, CMS rejected a plan to stabilize the CO-OP, which is Maine's largest writer of individual policies. The GAO report is titled "Federal Oversight Premiums and Enrollment for Consumer Operated and Oriented Plans in 2015" ....

According to a recent study, "cross-market mergers" ...

... of hospitals gaining system members in the same state (but in different local markets) had price increases of 6% to10% compared to control hospitals, while hospitals gaining system members out-of-state had no statistically significant changes in price.

Source: "The Price Effects of Cross-Market Hospital Mergers," Northwestern Kellogg School of Management, March 18, 2016,   

Friday, March 25, 2016

According to a recent survey of Americans who report being currently covered by health insurance:

  • 33% say their coverage is excellent
  • 40% say their coverage is good.
  • 20% say their coverage is fair
  • 5% say their coverage is poor

Source: Patients' Perspectives on Healthcare in the United States: A Look at Seven States and the Nation," NPR, Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, February 2016,

Majority of Physicians Accepted Pharma Payments in 2014

ProPublica recently conducted an analysis on the relationship between physician prescribing practices and money received from pharmaceutical companies in 2014. Here are some key findings from the report:

·         Nearly 90% of cardiologists received payments from a drug or device company in 2014.

·         7 in 10 internists and family practitioners received payments from a drug or device company in 2014.

·         Nationally, about 3 in 4 doctors across five common specialties received at least one payment in 2014.

·         Nevada has the highest proportion (90.3%) of doctors who received payments in 2014.

·         Internists who received no payments had an average brand-name prescribing rate of about 20%.

·         Internists who received more than $5,000/year prescribed brand-name drugs 30% of the time.

Source: NPR, March 17, 2016

According to a recent report, physician assistants in the U.S.

earn a median annual salary of about $95,000, and recently certified physician assistants carry a median educational debt of $112,500.

Source: "2014 Statistical Profile of Certified Physician Assistants by State: An Annual Report of the National Commission on Certification of Physician Assistants," National Commission on Certification of Physician Assistants, Inc., January 2016,   

“Agent and Broker Roadmap to Resources”

Be sure to take a look at the “Agent and Broker Roadmap to Resources” in the “Guidance” section of the Agents and Brokers Resources webpage.

The Roadmap to Resources:

  • Presents resources, such as checklists and troubleshooting tips to make it easier and faster for you to help consumers
  • Serves as a quick reference guide for resources you may find helpful as you navigate the Health Insurance Marketplace and assist individuals and small businesses select, enroll in, and use coverage
  • Explains coverage options available to consumers in the Marketplace
Provides graphic summaries of many eligibility and enrollment processes 

“Assisting Consumers with Complex Situations” webinar on Wednesday, March 30 from 1:00 PM to 2:30 PM Eastern Time.

Don’t forget to register for the “Assisting Consumers with Complex Situations” webinar on Wednesday, March 30 from 1:00 PM to 2:30 PM Eastern Time. Registration closes 24 hours before the webinar.


CMS subject matter experts (SMEs) will cover how you can help consumers manage commonly seen, but complex, health coverage situations. The webinar will include:

  • Determining if a consumer’s household is a multi-tax household and, if so, how to group family members for enrollment in qualified health plans (QHPs)
  • Enrolling family members for reasons of preference in different QHPs
  • Applying for, allocating, and reconciling advance payments of the premium tax credit in these complex situations
  • Making decisions when consumers have eligibility options (i.e., QHP coverage versus other coverage such as Medicare, Medicaid, or the Children’s Health Insurance Program)
  • Transitioning from an QHP to other coverage.

In addition to presenting relevant policy and step-by-step processes, SMEs will apply this guidance to a number of “real life” scenarios, and take your questions via the webinar’s online chat feature. The webinar will also offer links to resources on these topics that you can access anytime. 

To register for the webinar, please log in to If you have questions on the webinar registration process, visit the “Upcoming Agent and Broker Webinars” section of the Agents and Brokers Resources webpage for more information.

CMS Launches New Effort to Improve care for Nursing Facility Residents




March 24, 2016


Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries


CMS Launches New Effort to Improve care for Nursing Facility Residents

New payment model test for nursing facility care aims to reduce avoidable hospitalizations


The Centers for Medicare & Medicaid Services (CMS) today announced it will test whether a new payment model for nursing facilities and practitioners will further reduce avoidable hospitalizations, lower combined Medicare and Medicaid spending, and improve the quality of care received by nursing facility residents.

This next phase of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents seeks to reduce avoidable hospitalizations among beneficiaries eligible for Medicare and/or Medicaid by providing new payments to practitioners for engagement in multidisciplinary care planning activities. In addition, the participating skilled nursing facilities will receive payment to provide additional treatment for common medical conditions that often lead to avoidable hospitalizations.

Through this model, CMS would facilitate practitioner engagement when a nursing facility resident needs higher-intensity interventions due to an acute change in condition. Medicare currently pays physicians less for a comprehensive assessment at a skilled nursing facility than for the same assessment at a hospital. This model would equalize the payments between the sites of care. Removing potential barriers to effective treatment within a facility can improve the residents’ care experience and mitigate the need for disruptive and costly hospitalizations. For example, participating skilled nursing facilities will be expected to enhance their staff training and purchase new equipment to improve their capacity to provide intravenous therapy and cardiac monitoring.

“This Initiative has the potential to improve the care for the most frail, most vulnerable Medicare-Medicaid enrollees—long-stay residents of nursing facilities,” said Tim Engelhardt, Director of the Medicare-Medicaid Coordination Office. “Smarter spending can improve the quality of on-site care in nursing facilities and the assessment and management of conditions that too often now lead to unnecessary and costly hospitalizations.”

Since 2012, CMS has funded Enhanced Care and Coordination Providers (ECCPs) to test a model to improve care for long-stay nursing facility residents through clinical and educational interventions. The ECCPs currently collaborate with 143 long-term care facilities to provide on-site staff for training and preventive services and to improve the assessment and management of medical conditions. Early results from the first phase of the Initiative are promising, according to an independent evaluation. All seven sites generally showed a decline in all-cause hospitalizations and potentially avoidable hospitalizations, with four sites showing statistically significant reductions in at least one of the hospitalization measures. In addition, all sites generally showed reductions in Medicare expenditures relative to a comparison group in 2014, with statistically significant declines in total Medicare expenditures at two sites. This first phase of the Initiative will continue through 2016.

This new four-year payment phase of the Initiative, slated to begin fall 2016, will be implemented through cooperative agreements with six ECCPs. The six awardees are:

  • Alabama Quality Assurance Foundation – Alabama
  • HealthInsight of Nevada – Nevada and Colorado
  • Indiana University – Indiana
  • The Curators of the University of Missouri – Missouri 
  • The Greater New York Hospital Foundation, Inc. – New York
  • UPMC Community Provider Services – Pennsylvania 

The new model will be subject to a rigorous independent evaluation to determine the effects on cost and quality of care. ECCP awardees will implement the payment model with both their existing partner facilities, where they provide training and clinical interventions, and in a comparable number of additional facilities to be recruited over the next several months.

The Initiative is a collaboration of the CMS Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation, both created by the Affordable Care Act to test payment models to improve health care quality and reduce costs in the Medicare and Medicaid programs. The Initiative complements broader administration efforts to improve long-term care facilities, including proposed updates to the conditions of participation for nursing homes, improvements to the five-star rating system for consumers, and implementation of the new Skilled Nursing Facility Quality Reporting Program that ties skilled nursing facility payment to the reporting of quality measures.
For more information on this Initiative, including both current activities and this new phase, please visit:

Marketplace 101 Webinar

Join us for the CMS National Training Program

Marketplace 101 Webinar

April 7, 2016

1:00 – 2:30 pm ET


This webinar provides a high-level overview of the Affordable Care Act and the Health Insurance Marketplace, including information on coverage, tax credits, and fees.

3 ...

... Medicare Advantage prescription drug plans (Ultimate Health Plans, Inc., Health Net, Inc. and Tenet Healthcare Corp.) were penalized by CMS for failing to comply with federal regulations, several of them related to Part D.

"I would say [to price-raising pharma industry execs] go to ...

... your spiritual advisor, go to your pastor, go to your rabbi, go to wherever you go to and ask them, 'Is this the right thing to do?' And if that's not good enough, go to your mother. I can tell you my little 4'11" Italian mother would have looked at me and said, 'Johnny, you're a bad boy.'"
— John Bennett, M.D., CEO of Capital District Physicians' Health Plan, told the audience at the March 9 AHIP Nationa

$50 million ...

... will be spent by CVS Health Corp. over five years on an initiative — "Be the First" — to help drive the first tobacco-free generation in the U.S.

"There are more avenues of [cyber]attack against a hospital ...

...  than probably any other organization because everything is connected — your pharmacy, your patient records, your thermostat. When you hack a hospital, you can really hurt people, and that's why hospitals need to take this stuff seriously if they aren't already."

— Mark Lanterman, chief technology officer for Computer Forensic Services in Minnetonka, Minn., told AIS's Report on Medicare Compliance.

350 ...

... types of Medicare billing are now being reviewed by recovery audit contractors, down from 800 areas that were approved for RAC review when the program was "working at full capacity," according to the Council for Medicare Integrity.

According to a recent study comparing the use of prescription and over-the-counter medications ....

... by older adults ages 62 to 85 in 2005-2006 to their use in 2010-2011:

  • 84.1% of older adults used at least 1 prescription medication in 2005-2006 compared to 87.7% in 2010-2011
  • Concurrent use of at least 5 prescription medications rose from 30.6% in 2005-2006 to 35.8% in 2010-2011
  • Use of over-the-counter medications fell from 44.4% to 37.9%
  • Use of dietary supplements rose from 51.8% to 63.7%
  • About 15.1% of older adults were at risk for a potential major drug-drug interaction in 2010-2011, compared with about 8.4% at risk in 2005-2006

Source: "Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011," JAMA Internal Medicine, abstract only, March 21, 2016,

Tuesday, March 22, 2016

25% of Consumers Have Used a Retail Clinic

Oliver Wyman recently conducted a survey on consumer experiences with alternative care sites like retail health clinics and telehealth. Here are some key findings from the report:

·         70% of consumers are familiar with the concept of a health and wellness clinic within a retail store.

·         One-quarter of consumers have used a retail clinic, an increase of 11 percentage points from 2013.

·         78% said their retail clinic experience was the same or better than a traditional office visit.

·         3 in 10 said their retail clinic experience was better or much better than a traditional office visit.

·         17% of consumers say they would never use a retail clinic for any reason.

·         57% of consumers are now familiar with the concept of a remote health visit conducted via phone/video.

Source: Oliver Wyman, March 16, 2016

Monday, March 21, 2016

According to a recent survey, 40% of consumers ...

... who use health apps have discussed or shared mobile app data with their doctor in the past year.

Source: "Consumers’ Use of Health Apps and Wearables Doubled in Past Two Years, Accenture Survey Finds," Accenture Press Release, March 3, 2016,   

Most Americans Have a Positive Reaction to "Medicare-for-all"

The Kaiser Family Foundation recently conducted a survey on the public's view of the national health care system and where it's headed. Here are some key findings from the report:

·         36% say lawmakers should build on the Affordable Care Act to improve affordability and access to care.

·         1 in 4 would prefer guaranteed coverage through a single government plan.

·         60% of Republicans favor repealing the ACA.

·         Most Democrats (54%) support building on the ACA, while a third favor a single government plan.

·         Two thirds (64%) of Americans say they have a positive reaction to the term "Medicare-for-all."

·         38% say they have a positive reation to the term "socialized medicine."

Source: Kaiser Family Foundation, February 25, 2016

33% of Consumers Use Mobile Health Apps

Accenture recently released results of a survey on health app and wearable utilization. Here are some key findings from the report:

·         The number of consumers who use mobile health apps increased from 16% in 2014 to 33% today.

·         In the past year the number of consumers who use health wearables increased from 9% to 21%.

·         1 in 5 consumers were asked by a doctor to use wearables to track their health.

·         40% who use health apps have discussed or shared mobile app data with their doctor in the past year.

·         Consumers most frequently use health apps for fitness (cited by 59%) and diet/nutrition (52%).

·         29% of consumers said they prefer virtual doctor appointments to face-to-face appointments.

Source: Accenture, March 3, 2016