Guidance Issued on Medicaid Expansion, Health Plan Exchanges

On Monday, HHS released draft regulations that are intended to provide more guidance to states and health insurers on the Medicaid expansion and the creation of the health insurance exchanges under the Affordable Care Act, The Hill's "Healthwatch" reports.

About the Proposed Regulations

The 472-page document is intended to help streamline the process for determining eligibility requirements and notification of eligibility decisions for Medicaid (Baker, "Healthwatch," The Hill, 1/14).

More specifically, the proposed regulations offer guidance on:

• Appeals of eligibility requirements;
• Coordination between insurance exchanges and Medicaid;
• Roles of counselors who will assist residents in applying for coverage;
• Verification procedures for employer-sponsored coverage; and
• How to use updated Medicaid eligibility categories.

Under the proposed rules, states that operate their own exchange would be able to direct the exchanges to administer the appeals process. In addition, applicants who are denied coverage could to file a single appeal with exchange and Medicaid officials.

The rules also would permit states to impose a 90-day waiting period for children who are eligible for coverage under the Children's Health Insurance Program (Adams, CQ HealthBeat, 1/14). CMS Deputy Administrator Cindy Mann noted that any changes under the proposed regulations would not result in additional costs to states ("Healthwatch," The Hill, 1/14).

CMS is accepting public comment on the proposed regulations until Feb. 13 (CQ HealthBeat, 1/14).

Proposed Regulations Include Higher Cost-Sharing With States

Under the proposed regulations, states would be able to charge Medicaid beneficiaries slightly higher co-payments for certain services, the Washington Post's "Wonkblog" reports.

Under the rules, states could charge a maximum co-pay of $4 for any outpatient service used by beneficiaries whose annual income is below the federal poverty line, which is about $11,170 for a single person. Current regulations allow states to charge between $1.30 and $3.90 (Kliff, "Wonkblog," Washington Post, 1/14).

In addition, states could impose an $8 co-pay for non-preferred drugs and non-emergency use of hospital emergency departments on beneficiaries with incomes equal to or less than 150% of the poverty level, or those who have been exempt from cost-sharing (CQ HealthBeat, 1/14).

There would be no limit on cost-sharing for non-emergency use of EDs for beneficiaries with incomes exceeding 150% of the federal poverty level. Mann said the expansion of the cost-sharing parameters is intended to "promote more effective use of services" (Daly, Modern Healthcare, 1/14).

Mann noted that while the change is "not triggered by the [ACA] itself and is not a change to the law," it was "prompted by the context of states expanding Medicaid" ("Wonkblog," Washington Post, 1/14).