CMS releases proposed rules for health information exchanges

Healthcare IT NewsJanuary 17, 2013
The Centers for Medicare and Medicaid Services (CMS) has released a proposed rule that outlines further details about the standards and systems for states’ health insurance exchanges, Medicaid and the Children’s Health Insurance Programs (CHIP) to work together to meet consumer health needs, improve quality and lower costs in 2014.
The proposed rule released Jan. 14 also provides options for coordinating Medicaid, CHIP, and exchange communications to consumers about eligibility notices and appeals, and additional benefits and cost-sharing flexibility for state Medicaid programs under the Patient Protection and Affordable Care Act.
The intent is “to afford states substantial discretion in the design and operation of an exchange, with greater standardization provided where directed by the statute or where there are compelling practical, efficiency or consumer protection reasons,” according to the 474-page document.
The theme builds on the health insurance exchange rule in March 2012 “to continue to rely on the use of information technology and data matching to minimize administrative burden on applicants, states, and plans,” CMS said.
State-based exchanges may also turn to the Health and Human Services Department for verification of whether an individual has employer-sponsored coverage and conducting some types of appeals, according to Health and Human Services Secretary Kathleen Sebelius. 
The proposed rule “gives states more flexibility to implement the law in a way that works for them,” she said in an announcement accompanying release of the proposed rule. 
Under the healthcare law, adults who earn up to 133 percent of poverty, or $14,865 for an individual or $30,656 for a family of four, may be eligible for Medicaid coverage. Others may shop and compare plans for coverage through a health insurance exchange, where they may also determine if they are eligible for tax credits or other affordability programs.
The provisions include:
·         Process for a coordinated exchange and Medicaid appeals of eligibility determinations. Enrollees will first be able to have a preliminary case review by appeals staff in an informal resolution. If the enrollee is satisfied, the decision stands. Enrollees dissatisfied with the outcome would have rights to a full appeal. A federally-managed appeals process would be available to enrollees in the individual market. State-based exchanges could establish their own appeals processes following the rule’s standards, with individuals retaining the right to a federal appeal after exhausting the state-based appeals process. States also may coordinate appeals of eligibility decisions across Medicaid, CHIP and the exchange.
·         Notices and communications about eligibility for insurance affordability programs will be clear and accurate. The notices of insurance affordability programs will be combined, including Medicaid, CHIP, advance payments of the premium tax credit and cost-sharing reductions, as well as eligibility to enroll in a qualified health plan through the exchange.
·         Medicaid cost sharing of premiums will be updated and simplified. Additionally, states will be allowed to establish higher cost sharing for non-preferred drugs and to impose higher cost sharing for non-emergency use of the emergency department.
·         Eligibility categories will be streamlined. The eligibility categories that will be in effect in 2014 build on the Medicaid and CHIP eligibility final rule issued in March 2012. It shifts to use of the Modified Adjusted Gross Income, or MAGI, method for determining eligibility with most populations. It also simplifies and aligns the citizenship documentation process across Medicaid, CHIP and the exchange.
The proposed rule also outlines standards for the approval of application counselors, who will play an important role in assisting individuals in applying for and maintaining coverage in a qualified health plan through the exchange and insurance affordability programs.

In Good Hands: Adult Day Care in the US Industry Market Research Report Now Available

from IBISWorld
PRWeb – Thu, Jan 17, 2013
An aging population and an anticipated expansion in private healthcare coverage in line with the Patient Protection and Affordable Care Act are forecast to increase already growing demand for adult day-care services. For these reasons, industry research firm IBISWorld has added a report on the Adult Day Care industry to its growing industry report collection. Los Angeles, CA (PRWEB) January 17, 2013
The Adult Day Care industry has performed well over the past five years. The steadily aging population and expensive alternative long-term care options fueled demand for industry services. “Growth slowed over 2010 and 2011, though, as state and local governments faced budget shortfall stemming from the recession,” says IBISWorld industry analyst David Yang. “Households also had difficulty paying for services due to stagnant disposable income growth.” Still, other care options, like nursing homes, can cost five times more than adult day care. As a result, this industry quickly returned to strong growth in 2012 as the economy recovered and disposable income grew. In the five years to 2013, revenue is estimated to increase at an annualized rate of 2.0% to $6.2 billion.
Despite growth, profit has slightly declined since 2008 due to a slowdown in Medicaid funding for adult day care. Due to the recession, many states, such as California, attempted to cut or reduce adult day-care programs over 2010 and 2011. According to research from MetLife, government funding is estimated to contribute 55.0% of funding for industry programs. Consequently, profit declined. Despite the decline, many firms have entered this industry to meet the steadily growing demand for adult day care. In the five years to 2013, the number of enterprises increased an estimated 2.9% per year on average. “The majority of industry operators are relatively small companies,” according to Yang, “so theAdult Day Care industry is highly fragmented.” The two largest companies in the industry are Senior Care Centers of America and Easter Seals, a prominent nonprofit. Over the past five years, market share concentration has increased slightly due to Senior Care’s merger with Active Day, previously the largest company in the industry.
Over the next five years, the percentage of people aged 65 and older in the United States is projected to increase. As the population ages, the prevalence of Alzheimer’s and other physical and mental diseases will increase, bolstering demand for adult day-care services. The Patient Protection and Affordable Care Act is anticipated to increase private health insurance coverage, resulting in greater funding for this industry. Disposable income will also recover as the economy returns to growth, allowing households to better afford adult day-care services. As a result, IBISWorld forecasts that industry revenue will continue to grow in the five years to 2018. For more information, visit IBISWorld’s Adult Day Care in the US industry report page.
IBISWorld industry Report Key Topics
This industry provides social and basic health assistance, including transportation, meals, personal hygiene and therapeutic activities, to the elderly and individuals with mental or physical disabilities.
Services are typically provided during normal business hours through adult care centers. This industry does not include home care.
About IBISWorld Inc.
Recognized as the nation’s most trusted independent source of industry and market research, IBISWorld offers a comprehensive database of unique information and analysis on every US industry.
With an extensive online portfolio, valued for its depth and scope, the company equips clients with the insight necessary to make better business decisions. Headquartered in Los Angeles, IBISWorld serves a range of business, professional service and government organizations through more than 10 locations worldwide.
For more information, visit or call 1-800-330-3772.
Gavin Smith IBISWorld 310-866-5042 Email Information

11 states get extra $1.5 billion for online health insurance exchanges

11 states get extra $1.5 billion for online health insurance exchanges


By IFAwebnews Staff

Posted: January 18, 2013

The Department of Health and Human Services (HHS) has awarded an additional $1.5 billion in grants to 11 states to develop their online health insurance exchanges.

HHS Secretary Kathleen Sebelius, in announcing the grants, said the money is intended to ensure the states have the resources necessary to build online marketplaces that meets the needs of their residents.

California, Delaware, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oregon, and Vermont have all received portions of the Exchange Establishment Grants.

“These states are working to implement the health care law and we continue to support them as they build new affordable insurance marketplaces,” Sebelius said. “Starting in 2014, Americans in all states will have access to quality, affordable health insurance and these grants are helping to make that a reality.”

Beginning Jan. 1, 2014, Americans must be covered by health insurance as required by the Patient Protection and Affordable Care Act (PPACA). All exchanges must be operational by Oct. 1, 2013, to allow consumers to begin purchasing insurance online.

Delaware, Iowa, Michigan, Minnesota, North Carolina, and Vermont received awards today for Level One Exchange Establishment Grants, which are one-year grants states will use to build marketplaces.

California, Kentucky, Massachusetts, New York, and Oregon received Level Two Exchange Establishment Grants today. Level Two grants are multi-year awards to states to further develop their marketplaces.

PPACA requires all states to have an online insurance exchange.

A total of 19 states are operating their own exchanges, 25 defaulted and have passed the responsibility for creating and running their exchanges back to the federal government, and seven will operate as state-federal exchange partners.

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Raising the Medicare age could hurt young workers


By Tami Luhby CNN Money January 23, 2013: 10:15 AM ET


Raising the Medicare eligibility age won’t just affect older workers … it could ripple all the way down the career ladder.

If senior citizens can’t sign up for Medicare until age 67, many will likely stay on the job longer so they can keep their health insurance. That means it could be tougher for mid-career workers to move up, which in turn could make it harder for younger workers to secure entry-level positions, economists say.

“The only way to free up jobs at the bottom for young people is for older workers to retire,” said Sung Won Sohn, an economics professor at California State University Channel Islands. “No one wants to retire without health care.”

Options for cutting Medicare costs are back on the table as the Obama administration and lawmakers seek ways to reduce the deficit. President Obama has said he’d be willing to make modest changes to Medicare as part of the debt ceiling negotiations, while House Republicans are looking to overhaul the troubled entitlement programs.

Raising the eligibility age to 67 has been kicked around for years. Advocates say that the program should reflect the increased lifespan that Americans now enjoy, as well as the fact that there are fewer workers to support retirees.

Related: Obama’s economy: A snapshot

There’s already evidence that raising the entitlement age affects workers’ decisions to retire. A recent report from the Congressional Budget Office estimated that about half of the increase in the share of people age 62 or older who participated in the labor force during the 2000s can be attributed to the increase in the full retirement age of Social Security, which rose by one year to 66.

CBO expects a similar jump when the full retirement age for Social Security goes up to 67 in coming years. The share of men and women age 65 to 69 in the labor force should rise by 4 percentage points between 2012 and 2022, the report said.

Keeping senior citizens in the workforce could prove problematic for those down the career chain, particularly during weak labor conditions such as we’ve had in recent years.

 During the Great Recession, older workers hung onto their jobs, exacerbating the tough market for younger ones, said Sarah Watt, economic analyst with Wells Fargo Securities.

The share of Americans age 65 and over in the labor market rose to 18.5% in 2012, up from 16.0% in 2007. At the same time, the share of those age 25 to 54 fell to 81.4%, from 83.0%.

A similar scenario played out in the higher education arena after 1994 when universities were barred from instituting a mandatory retirement age of 70, said Carl Van Horn, director of Heldrich Center for Workforce Development at Rutgers University. More older professors are staying on the job, making it harder for younger PhDs to get tenure track positions or mid-career faculty to advance.

“There just weren’t as many openings,” he said.

Have you had trouble finding work or moving up as a result of older workers staying on the job longer? Email and you could be featured in an upcoming story.

First Published: January 23, 2013: 10:15 AM ET

Report: CMS Community Initiatives Could Reduce Health Costs

By Ankita Rao

JANUARY 22ND, 2013, 4:03 PM

 Kaiser Health News

A pilot program introduced by the U.S. Centers for Medicare and Medicaid Services to boost quality of care for seniors by developing community approaches to health problems could play a key role in bringing down costs, according to a new report in the Journal of the American Medical Association.

Quality Improvement Organizations, or QIOs, are private groups in each state and U.S. territory that contract with the government for three years to improve health services for Medicare patients. They are comprised of health care providers and other medical professionals, social services workers and other community members.

In Tuesday’s report, researchers found a 5.7 percent average reduction in 30-day hospital readmissions across 14 economically and demographically diverse communities over a two-year period. The number of patients admitted to the hospital within 30 days of a prior admission is one possible measure of efficiency, since the cost and burden of readmission can be preventable.

One in five Medicare patients returns to the hospital within 30 days of being discharged. The problem is an expensive one: in 2004, these readmissions cost Medicare $17.4 billion dollars.

The interventions used by the 14 community groups varied, but they included efforts to improve medication management and transitional care for patients leaving the hospital. Author Dr. Jane Brock, a coordinator at the Colorado Foundation for Medical Care’s Medicare quality improvement program, said that providing social services that can monitor and track patient treatment was one key to the project’s success.

Author Dr. Joanne Lynn, a director at the Altarum Institute, said the average community with 50,000 Medicare beneficiaries could have saved $4 million on readmissions alone if they used the various interventions that the QIOs practiced within their communities.

“Even those with low rates of readmissions had plenty [of hospitalizations] to be avoided,”Lynn said.

The report also included the results from patient satisfaction surveys, emergency room visits and mortality rates to screen for negative changes from the interventions. They found that other health factors remained stable or improved with the reduction of readmissions.

Brock said the successful outcomes would help expand the idea of community-based interventions.

“My hope is there is great recognition that this is the best purpose of the QIOs: We’re not competitors, we’re not regulatory, they really bring people together,” she said.



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