2. Payment and service delivery models
Another area to watch in 2018 is the direction of the Center for Medicare & Medicaid Innovation, which is tasked with supporting the development and testing of innovative healthcare payment and service delivery models. In September, CMS Administrator Seema Verma released a statement that reinforced CMS’ previous priority, which was a focus on the shift to value-based care. However, she also said a goal was to increase flexibility and make more programs voluntary.
Verma said that the goal of flexibility could be achieved through more state innovation waivers through Section 1332 of the ACA. These waivers allow states to pursue innovative strategies for providing their residents with access to high quality, affordable health insurance while retaining basic protections of the ACA. “While the federal government has approved a few such waivers that create reinsurance programs, the extent of their acceptance of wider ranging and inventive waivers is yet to be fully seen,” Day says. A number of states are in various stages of the process of developing 1332 waivers. Under a state reinsurance program, insurers are typically reimbursed for claims incurred by covered individuals for specified conditions or those that exceed a predetermined threshold, e.g., $50,000 to $250,000, as a way to allow individuals with pre-existing conditions to enroll in the same plans, receive the same coverage, and pay the same premiums as individuals without pre-existing conditions while reducing the adverse financial impact on insurers.
By approving 1332 waivers in Alaska, Oregon, and Minnesota, CMS has signaled that it will accept state reinsurance programs. “These reinsurance programs could lower rates in the individual marketplace and help mitigate the negative effects of discontinuing CSR payments because these states will have an additional pool of money to offset high-cost consumers,” Day says.
Other states looking at submitting 1332 waivers could see effects sooner if the Alexander-Murray bill passes. “One of the bill’s provisions is to shorten the timeline that the federal government has to review a waiver from 180 days to 90 days,” Day says. “Waivers that propose programs that have been approved for other states will have an even further expedited review process.”