While many states have chosen to take advantage of the Affordable Care Act’s expansion of Medicaid simply by expanding their existing Medicaid programs, a number of states are pursuing a different approach:  crafting programs that enable the newly eligible to select private insurance plans paid for by Medicaid.

This so-called private option has already been approved for Arkansas and Iowa; Pennsylvania has asked the federal government for approval to take a similar approach; and private option alternatives are currently in the works in New Hampshire, Tennessee, Utah, and Virginia.

Questions have arisen, however, about whether private option Medicaid plans will be required to offer the same services as conventional Medicaid programs.

At issue in particular are so-called wraparound services – services generally thought to be essential for the Medicaid population that are generally not offered by typical commercial insurance plans.  The best-known of such services is medical transportation:  helping low-income people get to the medical services they need.  Currently, one-third of such medical transportation is used to reach behavioral health services and 18 percent is for trips to dialysis.

Also at risk are Early and Period Screening, Diagnosis, and Treatment Services (EPSDT) – one of the centerpieces of Medicaid services …

Members of Congress are working to improve the manner in which Medicare pays for post-acute care for seniors.

Pursuing an area that MedPAC, which advises Congress on Medicare payment issues, has cited as in need of improvement and reform, a bipartisan group of senators and representatives solicited input from stakeholders and has now published a “discussion draft” of legislation that focuses on policy changes and standardized assessment data.

Among the post-acute-care providers addressed that could be affected by reform are home health agencies, long-term care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities.

The draft legislation would require Medicare to collect data so it can compare the quality of care delivered by the different provider types and help inform both discharge planning and Medicare payment policies.  Currently, it has been noted, there are circumstances under which Medicare pays different providers different amounts for the same kinds of care.

Learn more about the bipartisan discussion draft and the thinking behind it in this CQ HealthBeat article presented by the Commonwealth Fund and find the discussion draft itself here.…

The federal Centers for Medicare & Medicaid Services (CMS) has issued a letter to insurers describing the provider networks insurers will need to be certified as qualified health plans in the federally facilitated marketplace in 2015.

The final criteria emphasize creating networks that include providers that can help insured members obtain mental health and substance abuse services.  Insurers also will be required to include at least 30 percent of the “essential community providers” located in their area within their provider networks.  Essential community providers include disproportionate share hospitals, critical access hospitals, federally qualified health centers (FQHCs), children’s hospitals, and others.

See CMS’s final letter to insurers on qualified health plan criteria here.…

Citing income volatility among low-income Americans, the federal agency charged with analyzing Medicaid and the Children’s Health Insurance Program (CHIP) has recommended that Congress adopt measures to ensure that low-income Americans retain health insurance as their income fluctuates above and below the federal poverty level.

In its March report to Congress, MACPAC (the Medicaid and CHIP Payment and Access Commission) recommends that Congress empower states to extend coverage to eligible adults for an entire year to ensure that as those adults become eligible for Medicaid, lose Medicaid eligibility as their income rises, and then become eligible again because of unemployment or illness, they can maintain continuity of coverage and care.

MACPAC also recommends that Congress extend the current transitional medical assistance program so low-income parents who move into the workforce do not immediately lose their Medicaid coverage and that it eliminate the waiting period for CHIP eligibility and prohibit CHIP premiums for children from families whose income is less than 150 percent of the federal poverty level.

MACPAC is a non-partisan federal agency charged with providing policy and data analysis to Congress on Medicaid and CHIP and making recommendations to Congress, the Secretary of the U.S. Department of Health and …

The Medicare Payment Advisory Commission (MedPAC) has urged Congress to direct the administration to raise Medicare acute-care hospital inpatient and outpatient fee-for-service rates 3.25 percent in FY 2015.

It also recommended no rate increases for ambulatory surgical centers, dialysis providers, skilled nursing facilities, home health care services, inpatient rehabilitation facilities, long-term-care hospitals, and hospice facilities in the coming fiscal year.

In addition, MedPAC urge Congress to direct the administration to revised the prospective payment system for skilled nursing facilities; implement a value-based purchasing system for ambulatory surgery centers no later than 2016; and reduce payments to skilled nursing facilities and home health agencies with high risk-adjusted rates of hospital readmissions.

MedPAC also recommended paying physician offices and hospital outpatient departments the same for selected procedures and doing the same for acute-care and long-term hospitals in some cases.

And MedPAC urged Congress to abolish the current Medicare sustainable growth rate formula (SGR) used to pay doctors and to replace it with a 10-year path of statutory fee increases that includes larger updates for primary care than specialty care services.

An independent agency, MedPAC is required to issue annual recommendations to Congress but those recommendations are not binding on Congress.  Nevertheless, MedPAC’s …