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The 2011 State Legislators’ Check List for Health Reform Implementation

DECEMBER 2010

Rachel Morgan RN, BSN, Health Committee Director

National Conference of State Legislatures 444 North Capitol Street, N.W., Suite 515 Washington, D.C. 20001
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

Table of Contents
C

T
Title Page .............................................................................................................................................................................................................................................. 1

AMERICA
AN HEALTH BENEEFITS EXCHANGEES ..................................................................................................................................................................................... 6

PLANNING FOR STATE EXCHANGE IMPLEMEN


NTATION IN FY2014 ............................
. .............................................................................................................................................. 6

LEGISLATIVE CONSIDERRATIONS [Based on recommendationss from the NAIC model act] ................................................................................................................................ 7

G
Guidance utory Requirementts ................................................................................................................................................................................................... 8
for Statu

§ 1311 AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS (STATE PLANNING GRANTS) ..............................................................................................................................................12

EARLY INNOVATORS GRANT ........................................................................................................................................................................................................................12

R
Resource nts ...........................................................................................................................................................................................................................14
Documen

FRAUD, WASTE
W AND ABU
USE .......................................................................................................................................................................................................... 15

§
§6402. FUNDING TO FIGHT FRAUD, WASTEE, AND ABUSE. ..................................................................................................................................................................................15

§
§10201. WAIVER TRAANSPARENCY. ..............................................................................................................................................................................................................15

§
§6402. ENHANCED MEDICARE AND MEDICCAID PROGRAM INTEGRRITY PROVISIONS. ..................................................................................................................................................15

§
§6411. EXPANSION OF DIT CONTRACTOR (RAC) PROGRAM .......................................................................................................................................................16
O THE RECOVERY AUD

§
§6501. TERMINATION CIPATION UNDER MED
N OF PROVIDER PARTIC DICAID.................................................................................................................................................................16

§ 6502. MEDICAID EXXCLUSION FROM PARTIICIPATION RELATING TO CERTAIN OWNERSHIIP, CONTROL, AND MAANAGEMENT AFFILIATIO
ONS. ...............................................................................16

§ 6504. REQUIREMEN
NT TO REPORT EXPAND MENTS UNDER MMIS TO
DED SET OF DATA ELEM T DETECT FRAUD ......................................................................................................................16

§ 6505. PROHIBITION O THE UNITED STATEES ..............................................................................................................16


N ON PAYMENTS TO INSSTITUTIONS OR ENTITIES LOCATED OUTSIDE OF

§ 6506. OVERPAYMENTS ...........................................................................................................................................................................................................................17

Na
ational Conferencce of State Legisllatures 2
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

HEALTH CARE FACILITIES & WORKFORCE....................................................................................................................................................................................... 18

§ 5503. DISTRIBUTION OF ADDITIONAL RESSIDENCY POSITIONS. ...........................................................................................................................................................................18

§
§340H. Program off Payments to Teacching Health Cente
ers That Operate Graduate
G Medical Education Program
ms.................................................................................18

§ 10503. COMMUNITTY HEALTH CENTERS AND


A THE NATIONAL HEALTH
E SERVICE CORPS FUND. ...................................................................................................................................19

§ 6102. ACCOUNTABILITY REQUIREMENTS FOR


F SKILLED NURSING FACILITIES
F NG FACILITIES. ...........................................................................................................................19
AND NURSIN

OR QUALIFYING HOSPITTALS...............................................................................................................................................................................................19
§ 1109. PAYMENT FO

§ 10502. INFRASTRUCCTURE TO EXPAND ACCCESS TO CARE. [hospiital construction grants]....................................................................................................................................20

INSURAN
NCE REFORM ..................................................................................................................................................................................................................... 21

§
§1001 DEVELOPMENTT AND UTILIZATION OFF UNIFORM EXPLANATTION OF COVERAGE DOCUMENTS AND STAN
NDARDIZED DEFINITION
NS. .................................................................................21

§
§1001 BRINGING DOW ALTH CARE COVERAGE (MEDICAL LOSS RATIO [MLR]). ..............................................................................................................................21
WN THE COST OF HEA

LONG‐TEERM CARE .......................................................................................................................................................................................................................... 22

§ 8002. COMMUNITYY LIVING ASSISTANCE SERVICE AND SUPPORTTS. ....................................................................................................................................................................22

MEDICAID ...................................................................................................................................................................................................................................... 24

§
§2006. SPECIAL ADJU
USTMENT TO FMAP DETERMINATION FOR CERTAIN STATES RECO
OVERING FROM A MAJOR DISASTER................................................................................................24

§
§2001. STATE FINANCCIAL HARDSHIP EXEMPPTION. ............................................................................................................................................................................................24

§
§2005. O TERRITORIES. .............................................................................................................................................................................................................24
PAYMENTS TO

§
§6401. PROVIDER SCREENING AND OTHER ENROLLMENT REQUIRREMENTS UNDER MED
DICARE, MEDICAID, AN
ND CHIP. ....................................................................................................25

§
§2707. MEDICAID EMERGENCY
M PSYCHIATRRIC DEMONSTRATION PROJECT..............................................................................................................................................................26

Na
ational Conferencce of State Legisllatures 3
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

§
§2503. MEDICAID PHARMACY
H REIMBURSEMENT. ............................................................................................................................................................................................27

§
§2501. INCREASE MINIMUM REBATE PERCCENTAGE FOR SINGLE SOURCE DRUGS. ....................................................................................................................................................27

§
§2501. INCREASED REBATE
E PERCENTAGE FO
OR GENERIC DRUGS. ............................
. .............................................................................................................................................29

§
§2501. MAXIMUM REBATE AMOUNT. ..........................................................................................................................................................................................................29

§
§2401. COMMUNITY FIRST CHOICE OPTION. ...................................................................................................................................................................................................30

§
§10202. INCENTIVES FOR STATES TO OFFERR HOME AND COMMUN
NITY‐BASED SERVICES AS
A A LONG‐TERM CAREE ALTERNATIVE TO NURSING HOMES. ..................................................................30

§
§2702. PROHIBITS FEDERAL PAYMENTS TO STATES
S FOR MEDICAID O HEALTH CARE ACQUIIRED CONDITIONS. .........................................................................................32
D SERVICES RELATED TO

§
§2703. ONIC CONDITIONS. .....................................................................................................................33
STATE PLAN OPTION PROMOTING HEALTH HOMES FOR ENROLLEES WITH CHRO

§
§4108. INCENTIVES FO
OR PREVENTION OF CHRONIC
H DISEASE IN MEDICAID. [PROGRAM FOR HEALTHY LIFESTYYLES] ..........................................................................................................34

§
§2701. ADULT HEALTTH QUALITY MEASUREES. .................................................................................................................................................................................................34

MEDICARE...................................................................................................................................................................................................................................... 37

§
§3108. Permitting Physician Assistan
nts to Order Post‐H
Hospital Extended Care Services. .......................................................................................................................36

§
§3113. ex Diagnostic Laboratory Tests. .....................................................................................................................................................36
Treatment of Certain Comple

§
§3114. Improved Access
A d Nurse‐Midwife Services. ............................................................................................................................................................36
for Certified

§
§3301. Medicare Coverage
C ount Program................................................................................................................................................................................37
Gap Disco

§
§4103. MEDICARE COVERAGE
O OF ANNUAL WELLNESS VISIT PRO N. ..............................................................................................................37
OVIDING A PERSONALIZZED PREVENTION PLAN

§
§4104. NTIVE SERVICES IN MEDICARE. ..............................................................................................................................................................37
REMOVAL OF BARRIERS TO PREVEN

QUALITY
Y, PREVENTION & WELLNESS ............................................................................................................................................................................................. 38

§
§3011. NATIONAL STRATEGY
T FOR QUALITY
Y IMPROVEMENT IN HEALTH
E CARE. ........................................................................................................................................................38

Na
ational Conferencce of State Legisllatures 4
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

STATE EM
MPLOYEE BENEFIT CHANGES ............................................................................................................................................................................................ 39

Na
ational Conferencce of State Legisllatures 5
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
American n Health Benefits Exchange
E S
NOT IN COMMPLETE IMPLEMEENTATION
STARTED PROGRESS D DATE
A
FY2011 Actions ISSUE
PLANNING FOR STATE EXCHANGE IMPLEMENTATION IN FY2014
The Afffordable Care Act (ACA) establishes a plan to facilitatee the purchase and d sale of qualified health
h coverage in the
individual market, and to t provide optionss for small businesss through Americcan Health Benefitt Exchanges. The ACA A
directss states to establish
h and implement th he operation of an exchange no laterr than January 1, 2014. State‐establisshed
governnment or nonprofitt entities will certiffying plans and ideentify individuals eeligible for Medicaid, CHIP, and premmium
and coost‐sharing credits. States have severral options to struccture their exchanges and many of these t decisions will be
either made by state legislators or dependeent upon actions th hey take in session from 2011 through to 2014.

INITIAL GUIDANCE TO STATESS ON EXCHANGES


The Deepartment of Healtth and Human Servvices released guidaance November 18 8th to assist states in the development of
their exchanges. The secrretary plans to releease regulations for public comment in 2011, but has prrovided this guidan nce
to assisst states and territories with their overall planning, including the legislativve plans for 2011. This
T guidance is thee
first in a series of documeents that will be reeleased by HHS oveer the next three yeears. The categoriees of information in
n
this doocument cover the following:
ƒ Principles and Prioritties
ƒ Ouutline of Statutory Requirements
ƒ Claarifications and Po
olicy Guidance, and
ƒ Feederal Support for the
t Establishment of State based excchanges.
The exchanges have been n defined as a mecchanism for organizzing the health insu
urance marketplace to help consume
ers
mall business shop for
and sm f coverage in a way
w that permits eaasy comparison of available plan options based on pricee,
benefitts and services, and
d quality.

O INITIAL GUIDANCE DOCUMENT


LINK TO O — http://w
www.ncsl.org/documents/health/1118ExchGuid.pdf

Na
ational Conferencce of State Legisllatures 6
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions PLANNIN
NG FOR STATE EXCHAN
NGE IMPLEMENTATION
N IN FY2014 (continu
ued)
LEGISLATTIVE CONSIDERATIONS [Based on recomm
mendations from the
t NAIC model acct]
ƒ State options for conssideration relating to exchange structture:
1. Designation of thee oversight authority within:
ƒ a new or exissting state agency, or
ƒ an independent public agency, or quasi‐governmental agency,
2. Whether to establish a regional or in nterstate exchangee, and
3. Whether to operaate a unified exchan nge by merging thee SHOP Exchange1 and the exchange for the individual
market.
ƒ Dettermine governancce mechanisms if th he exchange is not located within a sttate agency including:
1. a governing board d, it’s size, composiition and terms,
2. determine the pro ocess of appointmeents to the board, their
t powers and d duties,
3. designation of com mmittees or other entities involved in n day‐to‐day responsibilities, and
4. licensure requirem ments.
ƒ he state exchange will require certain
If th n health benefits th
hat exceed the esseential benefits pacckage established by
b
thee Department of Heealth and Human Services.
S (States mu
ust develop a mech hanism to defray th
he cost of additiona
al
ben nefits in relation to premium and costt‐sharing assistance for enrollees.)
ƒ Dutties of the exchangge.
ƒ Dessignate state autho ority responsible foor health benefit pllan certification.
ƒ Con nform all state law to Federal ERISA fiduciary
f duties.
ƒ Graant necessary rule making authority to t appropriate state entities responsible for implementing state law relate ed
to exchanges.
e
ƒ Dettermine budget forr exchange, Medicaaid, and CHIP inforrmation technologyy systems needs caapable of meeting
inteeroperability requirement, (refer to resource
r documentts, Guidance for Exxchange and Medicaid IT Systems,
Verrsion 1.00).

1
“SHOP Exchange”
E is define
ed as meaning the Small
S Business Heaalth Options Prograam.

Na
ational Conferencce of State Legisllatures 7
1 State Legislatorrs’ Check List for Health Reform Implementation
The 2011

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions GUIDANCCE FOR STATUTORY REQUIREMENT
E (BASED ON
O HHS GUIDANCE RELEASED
E NOVEMBER 1 17, 2010)
According to the ACA therre are two basic typpes of federal requ
uirements for exchaanges which includ de 1) minimum
functionns exchanges mustt undertake directlyy or, in some casess, by contract; and 2) oversight responsibilities the
exchangges must exercise in certifying and monitoring the perfo ormance of Qualified Health Plans (Q QHPs). Plans
participating in the exchan
nges must also commply with state insuurance laws ad fed deral requirements in the Public Healtth
Service Act.

I. EXCCHANGE FUNCTIONS
ƒ hat an exchange must
Core functions th m meet:
1. Certification,, recertification and decertification of plans,
2. Operation off a toll‐free hotline,
3. Maintenancee of a website for providing
p informatiion on plans to currrent and prospective enrollees,
4. Assignment of
o a price and quality rating to plans,
5. Presentation
n of plan benefit op
ptions in a standard
dized format,
6. mination of eligibility for individuals in
Provision of information on Meedicaid and CHIP elligibility and determ i
these prograams,
7. Provision of an electronic calcu
ulator to determinee the actual cost off coverage taking in
nto account eligibillity
for premium tax credits and co
ost sharing reductio
ons,
8. Certification of individuals exem
mpt from the indivvidual responsibilityy requirement,
9. Provision of information on cerrtain individuals an
nd to employers,
10. Establishmen
nt of a Navigator program that provid
des grants to entities assisting consum
mers.
ƒ Additional Exchaange functions include:
1. Presentation
n of enrollee satisfaaction survey resultts,
2. Provision forr open enrollment periods,
3. Consultation
n with stakeholderss, including tribes, and
a
4. Publication of
o data on the exch
hange’s administrattive costs.

Na
ational Conferencce of State Legisllatures 8
1 State Legislatorrs’ Check List for Health Reform Implementation
The 2011

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions GUIDANCCE FOR STATUTORY REQUIREMENT
E (BASED ON
O HHS GUIDANCE RELEASED
E NOVEMBER 1 17, 2010) (CONTINUED)
I. OVEERSIGHT RESPONSIBILIITIES
ƒ HHS is required to develop regulato ory standards in fivve areas that insureers must meet in orrder to be certified
d as
QHP by an Exchange:
1. Marketing
2. Network adeequacy
3. Accreditation
n for performance measures
4. Quality improvement and repo
orting
5. ollment procedurees
Uniform enro

ƒ Additional areas where


w exchanges must
m ensure plan compliance
c with reegulatory standardss established by HH
HS
include:
1. Information on the availability of in‐network and out‐of‐network prroviders, including provider directorie
es
mmunity providers,
and availability of essential com
2. on of plan patterns and practices with
Consideratio h respect to past prremium increases and
a a submission of
o
the plan justifications for current premium increaases,
3. Public disclossure of plan data id
dentified, includingg claims handling p
policies, financial diisclosures, enrollm
ment
and disenrollment data, claims denials, rating praactices, cost sharingg for out of network coverage, and
mation identified byy HHS,
other inform
4. Timely inform
mation for consum
mers requesting theeir amount of cost ssharing for specificc services from
specified pro
oviders,
5. Information for participants in group health planss,
6. Information on plan quality imp
provement activitiees.

Na
ational Conferencce of State Legisllatures 9
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions CLARIFICAATION AND POLICY GUIDANCE
U (BASED ON HHS
H GUIDANCE RELEAASED NOVEMBER 17, 2
2010) (CONTINUED)

States should
s consider thee following issues in establishing an Exchange.
E
ƒ Orgaanizational Form. States have the op
ption to establish th
heir exchange as a governmental ageency or nonprofit
entity. Within the goveernmental agency category, the exch
hange could be hou
used within an existing state office, or it
coulld be an independeent public authority. Regardless of itss organizational forrm, the exchange must
m be publicly
acco
ountable, transpareent, and have technically competent leadership, with th
he capacity and authority to meet
fedeeral standards, including the discretio
on to determine wh
hether health plans offered through the
t exchange are “in

the interests of qualified individuals and qualified employeers”. Exchanges also
o must have securiity procedures and
privacy standards neceessary to receive taax data and other information needed for enrollment.
ƒ Ope
erating Model. Stattes have options to
o operate their excchange from an “acctive purchaser” mo
odel, in which the
exch
hange operates as large employers offten do in using maarket leverage and the tools of managed competition to
o
nego
otiate product offeerings with insurerss, to an “open marrketplace” model, in which the exchan
nge operates as a
clearinghouse that is open
o to all qualified
d insurers and reliees on market forces to generate prod
duct offerings. State
es
uld provide comparison shopping too
shou ols that promote ch
hoice based on pricce and quality and enable consumerss to
narrrow plan options based on their prefeerences.
ƒ Smaall Business (SHOP) Exchanges. Federral rules will provid
de a framework forr SHOP Exchanges, including options for
f
how
w employers can prrovide contribution
ns toward employeee coverage that meet standards for small
s business tax
cred
dits. States are perm
mitted to define “ssmall employers” as
a employers with o
one to 50 employeees for plan years
begiinning before January 1, 2016. Statess with differing legaal standards for counting employer siize should review
their definitions for co
onsistency with federal law.
ƒ Riskk Adjustment. Fedeeral rules in 2011 will ustment methods aand require all health plans to report
w outline risk adju
dem
mographic, diagnostic, and prescriptio
on drug data. Furth
her guidance addreessing risk adjustmeent rules and
form
mulas will be provid
ded in subsequent regulations. As speecified by the law, federal rules will apply
a risk adjustme
ent
conssistently to all plan
ns in the individual and small group markets,
m both insidee and outside of exxchanges. Federal
rules on reinsurance payments
p will applyy to all plans in the individual market,, and rules on risk corridors
c will applyy to
all qualified
q health plans in the individual and small group market,
m as specified in the law.

Na
ational Conferencce of State Legisllatures 10
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions CLARIFICAATION AND POLICY GUIDANCE
U (BASED ON HHS
H GUIDANCE RELEAASED NOVEMBER 17, 2
2010) (CONTINUED)
ƒ Perfformance Measure
es. Standardized pu
ublic data reporting will be used to evvaluate exchange performance
p and
assu
ure transparency.
ƒ Statte Choices. Federall rules will clarify th
hat the following policy
p areas, amongg others, are State decisions, although
HHSS may offer recomm
mendations and technical assistance to States as they m
make these decision
ns:

1. Wh
hether to form the exchange as a govvernmental agency or a non‐profit entity,
2. Wh
hether to form regiional exchanges orr establish interstatte coordination forr certain functions,
3. Wh
hether to elect the option under the ACA
A to use 50 emp
ployees as the cuto
off for small group market
m plans until
201
16, which would lim
mit access to exchaange coverage to employer
e groups off 50 or less,
4. Wh
hether to require additional benefits in the exchange beeyond the essential health benefits,
5. Wh
hether to establish a competitive bidd
ding process for plaans,
6. Wh
hether to extend so ons to the outside insurance market (beyond what is
ome or all exchangge‐specific regulatio
req
quired in the ACA).

ƒ Statte Authority. The feederal governmentt will work with thee Governor of the State as the chief executive
e officer
unleess authority to opeerate the exchangee has been delegatted to a specific authority through staate law.

Na
ational Conferencce of State Legisllatures 11
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions PLANNIN
NG FOR STATE EXCHAN
NGE IMPLEMENTATION
N IN FY2014 (continu
ued)
FUNDING
G OPPORTUNITY
§ 1311 AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS (STATE PLANNIN
NG GRANTS)
ƒ Autthorizes the Secrettary of Health and Human
H Services to
o award grants to sttates to support planning efforts in th
he
estaablishment of the American
A Health Benefit
B Exchange.
ƒ Graants must be award
ded within one yeaar of enactment of the Affordable Carre Act, March 2011
1.
ƒ Thee amount of the graants to each state will be determined
d by the secretary.
ƒ Planning grant recipieents may renew thee grant if the recipient—
1. is making progresss toward establishiing an Exchange; and implementing tthe insurance reforrms that comply with
the provisions within the health refo
orm law; and
2. nchmarks as established by the Secreetary.
is meeting any ben
nts may be awarde
No gran ed after January 1, 2015.
FY2011 Actions FUNDING
G OPPORTUNITY
EARLY INNOVATORS
N GRANT
ƒ Annnouncement releassed by OCIIO2 Octo ober 29, 2010.
ƒ Pro
ovides competitive incentives for states to design and im mplement the Inforrmation Technologgy (IT) infrastructurre
neeeded to operate Heealth Insurance Excchanges ‐ new com mpetitive insurancee market places thaat will help Americaans
andd small businesses purchase affordab ble private health in
nsurance starting inn 2014.
ƒ This competitive “Early Innovators” gran nt announcement willw reward States that demonstrate leadership in
devveloping cutting‐ed
dge and cost‐effecttive consumer‐baseed technologies an nd models for insurrance eligibility andd
enrrollment for Exchan
nges. These “Early Innovator” States will develop Exchange IT models, buiilding universally
essential componentss that can be adoptted and tailored byy other States. The innovations produ uced from this
Coooperative Agreemeent will be used to help keep costs do own for taxpayers, States, and the Fed deral Government.
Thee systems developeed through these Cooperative
C Agreem
ments will complem ment the health plaan information on
HeaalthCare.gov.
Two‐yeaar grants will be awwarded by February 15, 2011 to up to o five States or coalitions of States that have ambitious yet
achievable proposals that can yield IT modells and best practicees that will benefit all States. These States
S will lead the
way in developing
d consummer‐friendly, cost‐eeffective IT systemss that can be used and adopted by otther States and help
all Statees and the Federal government save money
m as they worrk to develop thesee new competitive market places.

2
OCIIO‐O
Office of Consumer Information and In
nsurance Oversightt.

Na
ational Conferencce of State Legisllatures 12
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions Rules
FEDERAL FUNDING FOR MEDICCAID ELIGIBILITY DETERRMINATIONS AND ENRROLLMENT ACTIVITIES PROPOSED RULES
ƒ CM
MS proposed rules were
w released Noveember 3, 2010.
ƒ Com mment period 60 days.
d
ƒ Pro
ovides an enhancedd FFP of 90 percentt for state expendittures for design, deevelopment, installlation or
enhhancement of systeems until calendar year 2015.
ƒ Pro ovides an enhancedd FFP of 75 percentt for maintenance and operation of systems before 201 15 if the system
alreeady meets standards and after 20155 for systems that have
h just become ccompliant.
Newly developed
d standardds will build upon the
t work of the Meedicaid Information n Technology Architecture (MITA) (se
ee
resource documents, MED DICAID INFORMATION TECHNOLOGY ARCHITECTURE (MITA)—fra amework documen nts)

Na
ational Conferencce of State Legisllatures 13
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
AMERICAN HEALTH BENEFITS EXCHANGES
X
NOT IN COMMPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
FY2011 Actions RESOURCCE DOCUMENTS
ƒ HHS INITIAL GUIDANCE TO T STATES ON EXCHANNGES NOVEMBER 18, 2010—
http://www.ncsl.org//documents/health h/1118ExchGuid.pd df
ƒ NATTIONAL ASSOCIATION OF INSURANCE COMM MISSIONER “Americaan Health Benefit Exxchange Model Actt” adopted 11/22/10,
http://www.naic.org//documents/comm mittees_b_exchanges_adopted_health_benefit_exchangges.pdf
ƒ STAATE PLANNING GRANTS—“EARLY INNOVATO OR” grants competitive funding to design and implemen nt the information
technology (IT) infrasttructure needed to
o operate Health Innsurance Exchangees.
1. announccement released October
O 29, 2010‐ http://www.ncsl.or
h rg/documents/health/InstEIgrts.pdf .
2. grant ap pplication package‐‐ http://www.ncsl.oorg/documents/heealth/EarlyInovGrtss.pdf .
ƒ GUIIDANCE FOR EXCHANG GE AND MEDICAID IT SYSTEMS, VERSION 1.00— http://www.cm ms.gov/apps/docs//Joint‐IT‐Guidance‐‐11‐
3‐10‐FINAL.pdf .
ƒ HHS Memorandum: Federal F Support annd Standards for Medicaid
M and Exchaange Information Technology System ms
http://www.healthcare.gov/center/letteers/improved_it_sys.pdf .
ƒ FED DERAL FUNDING FOR MEDICAID ELIGIBILITY DETERMINATIONS ANDD ENROLLMENT ACTIVVITIES PROPOSED RULEES—
http://www.ofr.gov/O OFRUpload/OFRDaata/2010‐27971_PI.pdf .
ƒ MEDICAID INFORMATION N TECHNOLOGY ARCHITTECTURE (MITA)—frramework docume ents are available to
o the public at
http://www.cms.gov//MedicaidInfoTech hArch/ .

Na
ational Conferencce of State Legisllatures 14
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
Fraud, Waste and Abuse
NOT IN COMPLETED EFFECTIVE
F
STARTED PROGRESS DATE
Legiislators should con
nsider the potentiaal financial impact of noncompliancee with fraud, waste
e, and abuse
provvisions in the Afforrdable Care Act.
Jan.. 1, 2011 ISSUE
§640
02. FUNDING TO FIGH
HT FRAUD, WASTE, AN
ND ABUSE.
ƒ Amends provision ns in the Social Secu
urity Act pertainingg to the Health Carre Fraud and Abusee Control Account by b
adding additional funding of $95 milllion for FY 2011, $55 million for FY 20 012, $30 million fo
or FY 2013 and 2014,
and $20 million foor FY 2015 and 2016.
ƒ The additional fun nding will be allocated for use by the Departments of Heealth and Human Services
S and Justicee
for their fraud and
d abuse control pro ograms, and for thee Medicare Integrity Program.
ƒ The additional fun nding will also suppport Medicaid Integgrity Program activvities.
LEGISSLATIVE CONSIDERATIONS
ƒ The Department of o Health and Human Services Office of the Inspector Geeneral has released d their plans for FYY
2011 which will innclude a review of State
S Medicaid ageencies’ program inttegrity activities. Thhey will examine sttate
policies and proceedures required by the federal regulations at 42 CFR pt. 455 to identify beest practices and ve erify
which proceduress are operating as intended. Medicaid d program integrityy includes identifyinng payment risks,
implementing actiions to minimize th he risks, and identifying and collecting overpayments.
FY
Y 2011 ISSUE
§102201. WAIVER TRANSPPARENCY. ‐ Applies to
t applications for or renewal of expeerimental projects,, pilots or
demmonstration projectts under Section 11115 of the Social Seecurity Act.
RESOOURCE DOCUMENTS
ƒ CMS Proposed Ru ules released Septeember 17, 2010, http://edocket.accesss.gpo.gov/2010/p pdf/2010‐23357.pdf
Jan.. 1, 2011 ISSUE
§640
02. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS.
ƒ Overpayments ‐ Requires
R that overp
payments be reporrted and returned w within 60 days from m the date the
overpayment wass identified or by th he date a correspon nding cost report w was due, whichever is later. The ACA
also provides thatt failure to return an
a overpayment within the timeframee is considered an “obligation” underr
the False Claims Act
A (“FCA”) and cou uld lead to liability for additional penaalties if a FCA violation is found to exist.
ƒ National Providerr Identifier ‐ Requirres the Secretary to o issue a regulation
n mandating that alla Medicare,
Medicaid, and CHIP providers includ de their NPI on enro ollment application ns.
ƒ Medicaid Manage ement Information n System ‐ Authorizzes the Secretary tto withhold the Fed deral matching
payment to Statess for medical assisttance expendituress when the State do oes not report enrollee encounter daata
in a timely manneer to the State’s Meedicaid Managemeent Information Sysstem (MMIS).

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
FRAUD, WASTE
A AND ABUSE
NOT IN COMPLETED EFFECTIVE
STARTED PROGRESS DATE
Jan
n. 1, 2011 ISSSUE
§66411. EXPANSION OF THET RECOVERY AUDITT CONTRACTOR (RAC)) PROGRAM ‐ Require es States to establiish contracts with one
o
or more Recovery Au udit Contractors (RACs). These state RAC
R contracts would be established tot identify
unnderpayments and overpayments and d to recoup overpaayments made for sservices provided under
u state Medicaaid
plaans as well as statee plan waivers.
RESOURCE DOCUMENTS
ƒ The CMS state Medicaid
M Directors letter October 1, 2010‐
2
http://www.cmss.gov/smdl/downlo oads/SMD10021.pd df.
ƒ CMS Proposed Rules R released Novvember 10, 2010, http://edocket.acce
h ess.gpo.gov/2010/pdf/2010‐28390.pdf.
Jan
n. 1, 2011 ISSSUE
§66501. TERMINATION OF PATION UNDER MEDIC
O PROVIDER PARTICIP CAID ‐ IF TERMINATED U
UNDER MEDICARE OR OTHER STATE PLAN ‐
Reequires States to teerminate individualls or entities from their
t Medicaid programs if the individ
duals or entities were
terrminated from Medicare or another state’s
s Medicaid program.
Jan
n. 1, 2011 ISSSUE
§ 6502.
6 MEDICAID EXCLLUSION FROM PARTICIPATION RELATING TO CERTAIN OWNERSHIP, CONTROL, AND MANAAGEMENT AFFILIATION NS.
Reequires Medicaid aggencies to exclude individuals or entiities from participaating in Medicaid fo
or a specified perio
od
of time if the entity or
o individual owns, controls, or manages an entity that: (1) has failed to reepay overpaymentss
duuring the period as determined by thee Secretary; (2) is suspended, excludeed, or terminated from
f participation in
any Medicaid program; or (3) is affiliateed with an individu
ual or entity that haas been suspended d, excluded, or
terrminated from Medicaid participation n.
Jan
n. 1, 2010 ISSSUE
§ 6504.
6 REQUIREMENT TO REPORT EXPANDED NTS UNDER MMIS TO
D SET OF DATA ELEMEN O DETECT FRAUD ‐ Req
quires states and
Meedicaid managed care
c entities to submit data elementss from MMIS as dettermined necessaryy by the Secretary for
pro
ogram integrity, prrogram oversight, and
a administration n.
As dettermined by ISSSUE
the Secretary.
§ 6505.
6 PROHIBITION ON
O PAYMENTS TO INSTITUTIONS OR ENTITIES LOCATED OUTSIDE OFF THE UNITED STATES ‐ Prohibits states frrom
maaking any paymentts for items or servvices provided undeer a Medicaid statee plan or waiver to any financial
insstitution or entity located outside of the
t United States.

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
FRAUD, WASTE
A AND ABUSE
NOT IN COMPLETED IMPLEEMENTATION
STARTED PROGRESS DATE
Jan
n. 1, 2011 ISSSUE
§ 6506.
6 OVERPAYMENTTS ‐ Extends the perriod for states to reepay uncollected o overpayments to on ne year; states are
still required to repayy collections in thee period collected. When overpaymen nts due to fraud arre pending a final
deetermination of thee amount of the ovverpayment due to an ongoing judiciaal or administrativee process, state
reppayments of the Feederal portion wou uld not be due untiil 30 days after the date of the final ju
udgment.
RESOURCE DOCUMENTS
Thhe Centers for Meddicare and Medicaiid Services memorrandum July 13, 2010,
Exxtended Period for Collection
C of Provid
der Overpayments, http://www.cms.ggov/smdl/downloaads/SMD10014.pdff
ADDITIONAL
D RESOURCESS
ƒ Presentation fro om the National Asssociation for Med dicaid Program Inteegrity Conference:: Angela Brice‐Smitth,
Director, Medicaaid Integrity Group
p, Center for Prograam Integrity, Centeers for Medicare an
nd Medicaid Services,
http://www.nam mpi.org/members//2010presentationss/MIGUpdate.pdf.

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1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
Health Caare Facilities & Wo
orkforce
NOT IN COMPLETED IMPLEMMENTATION
STARTED PROGRESS DATE
July 1, 2011 ISSUE
§ 5503. DISTRIBUTION OF ADDITIONAL RESIDENCCY POSITIONS.
ƒ Beginning July 1, 20
B 011, the secretary is
i directed to redisttribute unfilled ressidency positions allotted for paymennt
u
under the graduatee medical education n program, if they have been unfilled d for three cost reports, and convert
th
hem for training off primary care physsicians.
ƒ Grants an exception
G n to hospitals in rural areas with feweer than 250 acute ccare inpatient bedss and hospitals that
are part of a qualifyying entity which had a voluntary resiidency reduction plan approved.
FY 2011 ISSUE
§ 340H. PROGRAM OF PAYYMENTS TO TEACHING HEALTH CENTERS THAAT OPERATE GRADUATTE MEDICAL EDUCATIO
ON PROGRAMS.
ƒ Creates a new section of the Public Heealth Service Act reequiring HHS to maake payments for direct
C d and indirect
costs to qualified teeaching health centters (THCs) for the expansion of existting or the establish
hment of new
approved graduate medical education n (GME) training prrograms.
ƒ Payments will be in addition to GME payments
P p and will not count against tthe limit in number of full‐time
e
equivalent residentts paid for by Medicare or Children’s Hospital GME Proggrams.
ƒ P
Payments are to bee reduced by 25 percent if the THC faiils to report certain
n information.
ƒ A
Appropriates for this purpose may not exceed $230 million, for the period of FY2011 through
h FY2015.

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
HEALTH CARE
A FACILITIES & WORRKFORCE
NOT IN COMPLETED IMPLEEMENTATION
STARTED PROGRESS DATE
F
FY2011 ISSSUE (FUNDING)
§ 10503.
1 COMMUNITY HEALTH CENTERS AND
D THE NATIONAL HEALLTH SERVICE CORPS FU
UND.
ƒ Creates the Com
mmunity Health Cen
nter Fund.
ƒ Appropriates $1 billion for FY 2011
1, for community health center operaations and patient services,
s and
ƒ Also appropriatees $1.5 billion for health
h center consttruction and renovaation to be availab
ble for FY2011 through
FY2015 and remain available until expended.
Dec. 31, 2011 ISSSUE
§ 6102.
6 ACCOUNTABILITTY REQUIREMENTS FOR
R SKILLED NURSING FA G FACILITIES.
ACILITIES AND NURSING
ƒ Directs HHS to establish and implement a quality assurance and perform mance improvemeent program for
Medicare and Medicaid
M skilled nurrsing facilities (SNFs) and nursing facillities (NFs), including multi unit chain
ns of
facilities.
ƒ Calls for the estaablishment of stand
dards relating to quality assurance an
nd performance im
mprovement.
ƒ Facilities must develop and submitt a plan to meet theese standards to H
HHS by the end of FY
F 2015.
FY
Y 2011 ISSU
UE
§ 11
109. PAYMENT FOR QUALIFYING HOSPITALLS.
ƒ Increases Medicare payments to acute care hospitals in low‐cost countiees by $400 million for fiscal years 201 11
and 2012.
ƒ Qualifying hospitaals must be locatedd in counties rankeed in the lowest quartile of adjusted Medicare
M Part A an
nd B
benefit spending..
ƒ Payments will be in proportion to its Medicare inpatieent hospital payments relative to Med dicare inpatient
hospital paymentts for all qualifying hospitals.

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
HEALTH CARE
A FACILITIES & WORRKFORCE
NOT IN COMPLETED IMPLEMENTATION
STARTED PROGRESS DATE
Deeadline ISSU
UE [GRANT OPPORTUN
NITY]
Sept. 30, 2011 § 10
0502. INFRASTRUCTU
URE TO EXPAND ACCESSS TO CARE. [hospital construction gran
nts]
ƒ Authorizes $100 million
m beginning in
n FY 2010 through to September 30, 2011 for debt servvice, construction or
o
renovation of:
1. a health
h care facility that provides
p research
2. an inpatient tertiary care faacility, or
3. an outpaatient clinical servicces facility.
ƒ The applicable faccility must be affiliaated with an acadeemic health center at a public researcch university that
contains the statee’s sole public acaddemic medical and dental school.
ƒ To be eligible the governor of a statte must submit an application
a to HHSS that certifies that the new facility is
critical for the pro
ovision of greater access
a to care, the facility is essential to the viability of the schools, the
additional supporrt would be no more than 40 percentt of the total cost, aand the state has established
e a
dedicated fundingg mechanism neceessary to complete the project.

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
INSURANCEE REFORM
NOT IN COMPLETED IMPLEEMENTATION
STARTED PROGRESS DATE
F
FY2011 ISSSUE
Standards §1
1001 DEVELOPMENT AND
A UTILIZATION OF UNIFORM EXPLANATIO
ON OF COVERAGE DOC
CUMENTS AND STANDA
ARDIZED DEFINITIONSS.
develooped within
ƒ Directs HHS to develop standards within
w 12 months of o enactment for su ummaries and ben nefits information to
t
12 months
m of
be used by healtth insurers to inform beneficiaries of their insurance covverage.
enaactment.
ƒ Noncompliance by health insurers will result in a finee of $1000 per incid dent. Applies to all health insurers.
LEGGISLATIVE CONSIDERA
ATIONS
Implement use of
ƒ May preempt staate law if the statee requirements pro ovide less informatiion than is requiredd in the Affordable
e
ments within
docum
Care Act.
24 months
m of
ƒ Analyze and con nform as necessary state laws relatingg to required plan iinformation distrib
buted to health
enaactment.
insurance beneficiaries.
Jan
n. 1, 2011 ISSSUE
§1
1001 BRINGING DOWN THE COST OF HEALTTH CARE COVERAGE (M
MEDICAL LOSS RATIO [MLR]).
ƒ Requires health insurance issuers (group,
( individual, and grandfathered d health plans) to report
r to HHS annuually
their ratio of incurred loss (claims) plus the loss adjusstment expense (ch hange in contract reserves)
r to earnedd
premiums. The report
r must includee total premium reevenue, after accou unting for collectio
ons or receipts for risk
r
adjustment and risk corridors and payments of reinsu urance, that the cooverage expends:
1. On payment for medical servicees,
2. For health caare quality improveement,
3. On all non‐claims costs, excludiing federal and state taxes and licenssing or regulatory fees.f
ƒ Issuers will not have
h to account forr collections or receipts for risk adjusstment, risk, corridoors, and payments of
reinsurance untiil 2014.
ƒ Insurers will be required
r to providee an annual rebatee to enrollees if thee ratio of the amount of premium
revenue expended on costs versuss total premium revvenue for the plan year is less than 85 5 percent in the larrge
group market, or 80 percent in thee small group markket.
LEG
GISLATIVE CONSIDERA ATIONS
ƒ Review state meedical loss reporting requirements and harmonize state definitions, appliccation, and scope with w
those establisheed under federal law w.
ƒ Conform state laaw to mirror federaal requirements co oncerning calculatio on and timing of reebate payments
RESOURCE DOCUMENTS
ƒ OCIIO Interim Fiinal Rule posted 11 1/22/10, http://ww ww.ofr.gov/OFRUp pload/OFRData/201 10‐29596_PI.pdf .
ƒ The National Association of Insuraance Commissione ers Regulation adop pted 10/21/10,
http://www.naicc.org/documents/ccommittees_ex_mlr_reg_asadopted.pdf

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1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
LONG‐TERMM CARE
NOT IN COMPPLETED IMPLEMENTTATION
STARTED PROGRESS DATE
Jan. 1, 2011
2 ISSUE
§ 8002. COMMUNITY LIVING ASSISTANCE SERVICE AND SUPPORTS.
ƒ Establishes a new, volu untary, self‐funded
d public long‐term care
c insurance proogram, to be known n as the CLASS
Indeependence Benefit Plan, for the purch hase of communityy living assistance sservices and supports by individuals with w
funcctional limitations. Requires the Secreetary to develop an n actuarially sound benefit plan that ensures
e solvency fo
or
75 years; allows for a five‐year
f vesting peeriod for eligibility of benefits; createes benefit triggers that
t allow for the
deteermination of functtional limitation; an
nd provides cash benefit that is not leess than an average of $50 per day. No N
taxp
payer funds will be used to pay benefits under this provision.
ƒ Creaates a new national insurance program w have or develop functional impairrments to remain
m to help adults who
indeependent, employeed and stay a part of
o their communitiees.
ƒ Financed through voluntary payroll dedu ut enrollment similar to Medicare Part B), this program
uctions (with opt‐ou
will remove barriers to o independence and choice (e.g., housing modifications, assistive technolo ogies, personal
assisstance services, traansportation) by prroviding a cash ben
nefit to individuals unable to perform
m two or more
funcctional activities of daily living.
DEFINITION
NS
ƒ “Acttive enrollee” mean ns an individual wh ho has enrolled andd paid premiums to o maintain enrollm
ment. “Activities of
dailyy living” include eating, toileting, tran
nsferring, bathing, dressing,
d and incon
ntinence or the coggnitive equivalent.
ƒ An “eligible
“ beneficiaryy” has paid premiu
ums for at least 60 months and for at least 12 consecutivve months. (§ 3203
3)
CLASS INDDEPENDENT BENEFIT PLAN
ƒ o Health & Human Services to develo
Directs the Secretary of op two alternative benefit plans within specified limits.
ƒ The monthly maximum
m premiums will bee set by the Secretaary to ensure 75 yeears of solvency.
ƒ Therre is a five year vessting period for ben
nefit eligibility.
ƒ The benefit triggers wh
hen an individual iss unable to perform
m not less than two
o activities of daily living for at least 90
9
dayss.
ƒ The cash benefit will be not less than $50
0 per day.
ƒ Not later than Octoberr 1, 2012, the Secreetary will designatee a CLASS benefit p
plan, taking into consideration the
ommendations of the CLASS Independ
reco dence Advisory Cou uncil.

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1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
LONG‐TERMM CARE
NOT IN COMPPLETED IMPLEMENNTATION
STARTED PROGRESS DATTE
Jan. 1, 2011 ISSUE
§ 8002
2. COMMUNITY LIVING
G ASSISTANCE SERVICEE AND SUPPORTS. (con
ntinued)
ENROLLMENT AND DISENROLLLMENT
ƒ Thhe Secretary will esstablish proceduress to allow for volun
ntary automatic enrollment by emplo oyers, as well as
altternative enrollment processes for seelf‐employed, employees of non‐partticipating employerrs, spouses and
others. Individuals may
m choose to waivve enrollment in CLLASS in a form and manner to be estaablished by the
Seecretary. Employee es must opt‐out of the program or th hey will be enrolled
d automatically.
ƒ Premiums will be deducted from wages or self‐employmeent income according to procedures established by the
Seecretary.
BENEFITTS
ƒ opriate cash benefitts to which they arre entitled, advocacy services, and
Eliigible beneficiariess will receive appro
ad
dvice and assistance counseling.
ƒ Caash benefits will bee paid into a Life Ind
dependence Accou unt to purchase non‐medical servicess and supports needed
to maintain a beneficiary’s independen nce at home or in another
a residential setting, including home modification ns,
assistive technology,, accessible transpo ortation, homemakker services, respitte care, personal asssistance services,
ome care aides, and
ho d added nursing su upport.
CLASS INDEPENDENCE FUND
ƒ he CLASS Independence Fund will be located in the Department of the Treeasury and the Secrretary of the Treasury
Th
wiill act as the Managging Trustee.
ƒ A CLASS Independen nce Fund Board of Trustees
T will includ
de the Commission
ner of Social Securitty, the Secretary off
the Treasury, the Seccretary of Labor, th
he Secretary of Heaalth & Human Servvices, and two memmbers of the publicc.
CLASS INDEPENDENCE ADVISORY COUNCIL
ƒ Th
he CLASS Independence Advisory Cou uncil, created under this Title, will include not more than 15 members,
naamed by the Presiddent, a majority of whom
w will include representatives off individuals who participate
p or are likkely
to participate in the CLASS program.
ƒ he Council will advise the Secretary on
Th n matters of generral policy relating to
o CLASS
RESOURRCE DOCUMENTS
CRS report: Community Living
L Assistance Seervices and Supporrts (CLASS) Provisio
ons in the Patient Protection
P and
Affordaable Care Act (PPA
ACA), http://www.n ncsl.org/documents/health/CLASS.pd df .

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COMPLETED
O IMPLEM
MENTATION
STARTED PROGRESS DATE
Jan. 1, 2011 ISSUE [B
BUDGET ITEM]
§2006.. SPECIAL ADJUSTMEN
NT TO FMAP DETERMINATION FOR CERTAIN
N STATES RECOVERING
G FROM A MAJOR DISA
ASTER.
ƒ Reeduces projected decreases in federal Medicaid matchin ng funds as a result of the regular updating process, forr
staates that have expeerienced major dissaster.
ƒ To
o qualify as a “disasster recovery FMAP P adjustment statee”, a state must havve over the past seeven fiscal years
received a Presidential declaration of a major disaster under the provisions of sec. 401 of the Robert T. Stafford
Disaster Relief and Emergency Assistan nce Act and every county
c or Parrish in
n the state statewide was eligible for
oth individual and public
bo p assistance.
Jan. 1, 2011 ISSUE [B
BUDGET ITEM]
§2001.. STATE FINANCIAL HARDSHIP
A EXEMPTION.
ƒ Beetween January 1, 2011
2 and Decembeer 31, 2013, a statee is exempt from th he maintenance‐off‐effort for optionaal
noon‐pregnant, non‐d disabled adult popu ulations above 1333 percent of the fedderal poverty level if the state certifie
es
to the Secretary thatt the state is experiencing a budget deficit for the year iin which the certifiication is made or
prrojects to have a bu
udget deficit for a succeeding
s state fiscal year.
LEGISLAATIVE CONSIDERATIONS
ƒ A state
s he necessary certification that they arre experiencing a b
may make th budget deficit on orr after December 31,
3
20
010.
July 1,
1 2011 ISSUE [B
BUDGET ITEM]
§2005.. PAYMENTS TO TERRITORIES.
ƒ Beeginning in July 1, 2011
2 through Septeember 30, 2019, all territories’ FMAP P rate and spendingg caps will be
inccreased.
ƒ i 2014 to provide coverage to childleess adults who met income eligibilityy standards consiste
Reequires territories in ent
wiith those already established for pareents by the territorries.
ƒ Provides that the cosst of providing coverage to newly eliggible individuals wiill not count toward
ds the spending caap.
ORIES AND THE HEALTH
TERRITO H INSURANCE EXCHANG
GES
Each teerritory will have a one‐time option to
t “opt‐in” to state (or territory)‐baseed insurance exchanges in 2014.

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COMPLETED
O IMPLEM
MENTATION
STARTED PROGRESS DATE
Marcch 2011 ISSUE
§6401.. PROVIDER SCREENING AND OTHER ENROLLLMENT REQUIREMENTTS UNDER MEDICARE, MEDICAID, AND CHIP
P.
ƒ Directs HHS in consu
ultation with the Offfice of the Inspecttor General to establish procedures fo
or screening of
prroviders and suppliers who enroll in the Medicare, Medicaid, and CHIP pro ograms.
ƒ Att a minimum the prrocedures would in
nclude a process fo
or screening, enhan
nced oversight meaasures, disclosure
requirements, morattoriums on enrollm
ment, and requirem ments for developin
ng compliance proggrams.
ƒ o cover the costs off the screening, cerrtain providers would be subject to feees. Fees would staart at $500 for
To
insstitutional providers and would increease by the rate of inflation thereafteer.
ƒ Th
he HHS may exemp
pt the fees if they im
mpose a hardship.
ƒ En uirements will begiin March 2011 for all new providers in the programs.
nforcement of compliance of the requ
ƒ Co
ompliance for all cu
urrent providers wiill go into effect tw
wo years after enacctment of the ACA in
i 2013.
LEGISLAATIVE CONSIDERATIONS
In addiition to the requireements listed above, the Office of thee inspector generall plans to review inn their FY 2011 worrk
plan ho
ow states ensure that Medicaid manaaged care plans folllow a structured p process for credenttialing and
recredentialing of providers. Regulations att 42 CFR 438.214 reequire states to ensure that managed d care plans servingg
the Meedicaid population implement written n policies for selecttion and retention of providers. Each
h managed care plaan
must document
d its proceess for credentialing and recredentialing providers that have signed contraacts or participation
agreemments. Plans must not n employ or conttract with providess excluded from paarticipation in federal health care
programs. They will also be examining how w CMS ensures that states comply with requirements forr provider
credenntialing by Medicaid d managed care plans.
RESOURRCE DOCUMENT
ƒ MS Proposed Rule published September 23, 2010. http://edocket.access.ggpo.gov/2010/pdf//2010‐23579.pdf
CM
ƒ HH
HS presentation du
uring the National Association for Meedicaid Program Inttegrity Conferencee September 2010,
http://www.nampi.oorg/members/2010 0presentations/MIGUpdate.pdf.

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The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COM
MPLETED IMPLEMEN
NTATION
STARTED PROGRESS DATE
A
FY 20
011 ISSUE [D
DEMONSTRATION]
§2707. MEDICAID EMERGENCCY PSYCHIATRIC DEMO
ONSTRATION PROJECT.
ƒ Reqquires the Secretarry of HHS to establish a three‐year Medicaid demonstraation project in up to eight states.
ƒ Parrticipating states would
w be required to
t reimburse certaiin institutions for m
mental disease (IMDs) for services
pro
ovided to Medicaid d beneficiaries betw
ween the ages of 21 and 65 who are iin need of medical assistance to stabilize
an emergency psychiaatric condition.
APPROPRRIATIONS
ƒ App
propriates $75 million for FY 2011. Th
hese funds will rem
main available for o
obligation through December 31, 201
15.
EVALUATTION
ƒ Directs the Secretary to conduct an evaluation to determine the impact of th
he demonstration project and to makke
reccommendations as to whether the deemonstration projeect should be continnued after Decembber 31, 2013 and
exppanded nationwidee.
REPORT TO
T CONGRESS

ƒ Directs the Secretary to submit a reportt to Congress no latter than Decemberr 31, 2013 and makke available to the
pubblic a report on thee findings of the evvaluation.
RESOURCCE DOCUMENT
ƒ Sub
bstance Abuse and
d Mental Health Seervices Administration (SAMHSA) document‐
http://www.samhsa.ggov/healthreform//docs/Medicaid_Emmergency_Psychiattric_Demo_508.pdf

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1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COM
MPLETED IMPLEMEN
NTATION
STARTED PROGRESS DATE
A
October 1, 2010 ISSUE
CHANGESS TO MEDICAID PAYM
MENT FOR PRESCRIPTIO
ON DRUGS
§2503. MEDICAID PHARMACYY REIMBURSEMENT.
ƒ Chaanges the Federal upper
u payment lim
mit (FUL) to no less than 175 percent o
of the weighted avverage (determined
d on
thee basis of utilization
n) of the most receent average manufaacturer prices (AMPs) for pharmaceu utically and
theerapeutically equivaalent multiple sourrce drugs availablee nationally through
h retail communityy pharmacies.
ƒ Establishes a new formula for determining AMP based on sales to wholesaleers and sales to retaail community
phaarmacies.
ƒ Effeective on the first day
d of the first caleendar year quarter that begins at leasst 180 days after th
he date of enactme
ent
of this
t Act, without reegard to whether or o not final regulations to carry out su
uch amendments have h been
pro
omulgated by such date.
RESOURCCE DOCUMENT
ƒ CM MS FINAL RULE NOVEM MBER 15, 2010— Medicaid Program; Withdrawal
W of Deteermination of Averrage Manufacturer
Pricce, Multiple Sourcee Drug Definition, and
a Upper Limits fo
or Multiple Source Drugs
HTTTP://EDOCKET.ACCESSS.GPO.GOV/2010/PDF/2010‐28649.PDF
ƒ CM MS memo September 28, 2010, Reviseed Policy on Federa al Offset of Rebatess,
httpp://www.cms.gov//smdl/downloads/S /SMD10019.pdf
Jan. 1, 2010 ISSUE
§2501. INCREASE MINIMUM REBATE PERCENTAGE FOR SINGLE SOURCE DRUGS.
ƒ Increases the minimu
um manufacturer reebate for brand‐naame drugs purchased by state Medicaaid programs from
15.1% of average mannufacturer price to
o 23.1% of average manufacturer pricce.
Increasee Minimum Rebatee Percentage for Clotting Factors and
d Drugs Approved b
by the FDA for Pedia
atric Use Only
ƒ Increases the minimu
um manufacturer reebate for brand‐naame drugs purchased by state Medicaaid programs from
15.1% of average mannufacturer price to
o 17.1% of average manufacturer pricce.
Application of Rebates to New Formulations of Existing Drugs
ƒ Thee rebate for line exxtension drugs will be the greater of the
t amount compu uted under the rebaate statute or the
pro
oduct of the AMP fo or the line extensio
on drug multiplied by the highest add
ditional rebate for any strength of the
e
origginal brand name drug.
d

Na
ational Conferencce of State Legisllatures 27
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COM
MPLETED IMPLEMEN
NTATION
STARTED PROGRESS DATE
A
ISSUE
§2501. INCREASE MINIMUM REBATE PERCENTAGE FOR SINGLE SOURCE DRUGS. (CONTINUED)

Rebatess for Drugs Dispenssed by Medicaid Managed Care Organizations (MCOs)


ƒ Req
quires manufactureers to pay rebates for drugs dispenseed by Medicaid MC
COs, effective Marcch 23, 2010.
Limit on
n Total Rebate Liab
bility
ƒ Lim
mits total rebate liability on an individual single source or
o innovator multip
ple source drug to 100
1 percent of AMP
for that drug product. Other features off the drug rebate program, such as th he Medicaid's best price provision,
would remain unchan nged.
RESOURCCE DOCUMENT
CMS memo
m September 28, 2010, Reviseed Policy on Federral Offset of Reba
ates,
http:///www.cms.gov/sm
mdl/downloads/SSMD10019.pdf

Na
ational Conferencce of State Legisllatures 28
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COM
MPLETED IMPLEMEN NTATION
STARTED PROGRESS DATE
A
Jan. 1,, 2010 ISSUE
§2501. INCREASED REBATE PERCENTAGE
E FOR GENEERIC DRUGS.
ƒ Increases the rebate percentage
p for non
n innovator, multip
ple source drugs to
o 13% of AMP.
RESOURCCE DOCUMENT
ƒ CM
MS memo September 28, 2010, Reviseed Policy on Federa
al Offset of Rebatess,
http
p://www.cms.gov//smdl/downloads/S
/SMD10019.pdf
ISSUE
§2501. MAXIMUM REBATE AMOUNT.
Increasees the amount of rebates
r that drug manufacturers
m are required to pay unnder the Medicaid drug
d rebate prograam,
with diffferent formulas fo
or single source and
d innovator multiple source drugs (brrand name drugs), noninnovator
multiplee source drugs (genneric drugs), and drugs that are line extensions
e of a singgle source drug or an innovator multiiple
source drug,
d effective January 1, 2010. The Affordable
A Care Acct also required thaat amounts “attribuutable” to these
increaseed rebates be remiitted to the Federaal government drugg.
RESOURCCE DOCUMENT
CMS me emo September 28
8, 2010, Revised Po
olicy on Federal Offfset of Rebates,
http://w
www.cms.gov/smddl/downloads/SMD D10019.pdf

Na
ational Conferencce of State Legisllatures 29
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COM
MPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
Oct. 1,, 2011 ISSUE [BUDGET
U ITEM]
§2401. COMMUNITY FIRST CH
HOICE OPTION.
State Pllan Option to Provide Home and Community‐Based Atteendant Services and
d Supports
ƒ Estaablishes an optionaal Medicaid benefit which allows stattes to offer commu unity‐based attend dant services and
suppports to Medicaid beneficiaries to asssist in accomplishiing activities of daily living, instrumen
ntal activities of daaily
livin
ng, and health related tasks through hands‐on assistancce, supervision, or cueing in a person n‐centered plan thaat is
bassed on an assessmeent of functional neeed.
ƒ Proovides an enhanced onal six percentagee points for reimbursable expenses in the
d federal matchingg rate of an additio
proogram.
ƒ Con nsider the need forr any statutory changes made necessary to accommodaate a state plan am mendment if your sttate
optts to participate in this program.
RESOURCCE DOCUMENT
Nationaal Association of Sttate Units on Agingg (NASUA), LONG‐TTERM CARE IN BRIEF: Explaining the Medicaid Commun
nity
First Choice Option,
www.nasuad.org/d
http://w documentation/acaa/NASUAD_materiaals/ltcb_communittyfirstchoiceoption n.pdf.
Oct. 1,, 2011 ISSUE [BUDGET
U ITEM]
§10202. INCENTIVES FOR STAATES TO OFFER HOME AND
A COMMUNITY‐BASSED SERVICES AS A LON
NG‐TERM CARE ALTERN
NATIVE TO NURSING
HOMES.
ƒ Inceentivizes states thaat undertake structtural reforms in theeir Medicaid progrrams designed to create home and
com
mmunity based serrvices (HCBS) as a viable
v alternative to
o nursing home care with a targeted enhanced FMAP.
ƒ States may participatee through a waiverr or a state plan am mendment.
ƒ States that choose a SPA
S would be able to include individu uals with incomes uup to 300 percent of
o the maximum
pplemental Security Income paymentt.
Sup
ƒ Fun
nding for the nursin ng home diversion program would bee available for five years beginning in 2011.

Na
ational Conferencce of State Legisllatures 30
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COM
MPLETED IMPLEMEENTATION
STARTED PROGRESS DATE
A
Oct. 1,
1 2011 ISSUE [BUDGET ITEM]
2. INCENTIVES FOR STAATES TO OFFER HOME AND
§10202 A COMMUNITY‐BASSED SERVICES AS A LON
NG‐TERM CARE ALTERN
NATIVE TO NURSING
HOMES. (continued)
ng Payments
Enhanced Federal Matchin
ƒ MAP increases will be
FM b tied to the perceentage of a state’s LTC services and supports offered th hrough HCBS, with
low
wer increases goingg to states needingg fewer reforms as follows:
ƒ Staates with less than 25 percent of theirr total Medicaid lon ng‐term care expenditures for FY 200 09 on HCBS will sett
theeir target for spendding 25 percent for these services, to be achieved by Occtober 1, 2015. The ese states will rece eive
a 5 percentage point increase in their FMAP.
F
ƒ Othher participating sttates will set their target
t percentage for HCBS as a percentage of their Meedicaid long term
serrvices and supportss spending at 50 peercent, to be achievved by October 1, 2015. These statess will receive a 2
perrcentage point increase.
ƒ Maaintenance of Efforrt and Other Requirrements
ƒ Staates must maintain their eligibility staandards, methodolo ogies, or procedurees for determiningg eligibility for these
e
serrvices at levels thatt are no more restrrictive than those in
n place on Decembber 31, 2010.
ƒ Req quires that the addditional federal funds be used to pay for new or expanded offerings of non n‐institutional‐base ed
lon
ng‐term services an nd supports.
ƒ Req quires states to implement several sttructural changes to their Medicaid programs within sixx‐months of
appplication, includingg:
ƒ the implementatio on of a ―no wrongg door policy wherre beneficiaries maay access LTC servicces and supports
through a coordin nated network, ageency or other statewide system;
ƒ the development of conflict‐free casse management seervices; and
ƒ development of core assessment insstruments to deterrmine eligibility forr non‐institutionallyy‐based long‐term
services and supports.
ƒ Req quires state to collect data tracking service use, quality,, and outcomes by beneficiaries and their
t families.
Funding
g
ƒ $3 billion in federal matching
m od between October
funds will be available to inccentivize states for the five‐year perio
1, 2011
2 and Septemb ber 30, 2016.
ƒ Connsider the need forr any statutory chaanges made necesssary to accommodaate a state plan am mendment if your sttate
optts to participate in this program.
RESOURCCE DOCUMENT
ƒ Nattional Association of State Units on Aging
A (NASUA), LO
ONG‐TERM CARE IN
N BRIEF: Explaining the Medicaid
Commmunity First Choice Option,
http://www.nasuad.o org/documentation n/aca/NASUAD_maaterials/ltcb_comm
munityfirstchoiceopption.pdf

Na
ational Conferencce of State Legisllatures 31
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COMPLETED
O IMPLEMMENTATION
STARTED PROGRESS DATE
July 1,
1 2011 ISSUE
§2702.. PROHIBITS FEDERAL PAYMENTS
P TO STATES FOR MEDICAID SERVIC ONDITIONS.
CES RELATED TO HEALTTH CARE ACQUIRED CO
[HEALTH
H‐CARE ACQUIRED CONDITIONS
O (HACS)]
ƒ Will be defined by th
W he secretary and co onsistent with the definition
d of hospittal acquired condittions3 under
Medicare, but would d not be limited to conditions acquireed in hospitals.
ƒ Staate Medicaid programs that continuee to reimburse heaalth care providers for services associated with a health
care acquired condittion will no longer receive
r the federal match for those sservices.
ƒ W
When the Medicare rule affecting claimms payment was im mplemented severaal states adopted similar
s reimbursemment
prractices found in th
he federal rule for hospital
h claims, som
me states opted to o negotiated agreem ments with their laarge
hoospital systems andd the state hospital associations to reefrain from billing w
when these events occurred.
LEGISLAATIVE CONSIDERATIONS
ƒ Leegislative intervention may be needed d to enable state Medicaid
M agencies tto adopt reimburseement practices that
restrict payment for health care acquirred conditions.
ƒ Coonsider budgetary impact if state Med dicaid policies do not
n conform to CM MS requirements for nonpayment.
ƒ Leegislators may wantt to consider a hold d harmless provisioon If none exists in
n state law protecting Medicaid
beeneficiaries for resp
ponsibility of paym
ment for services wh hen an error is mad de on the part of a provider, either
addministrative or a practice
p error that applies
a to the HACC provisions.
RESOURRCE DOCUMENTS
ƒ Naational Guideline Clearinghouse
C p://www.guideline.gov/resources/ho
http ospital‐acquired‐conditions.aspx

3
Deficit Red
duction Act Sec. 5001. Hospital
H Quality Improvvement: (c) Quality Adju
ustment in DRG Payments for Certain Hospitall Acquired Infections‐(1 1) Amends Section 1886 6(d)(4) of the Social Security Act by adding
language that states that for disccharges occurring after October 1, 2008, the diagnosis
d related group (DRG) assigned may noot result in a higher payyment based on a secon ndary diagnosis associated with conditions
identified by the secretary that could
c have reasonably been
b avoided through the
t application of evideence‐based guidelines. Hospitals
H will be requireed to report the second
dary diagnosis present ono admission of the
patient.

Na
ational Conferencce of State Legisllatures 32
1 State Legislatorrs’ Check List for Health Reform Implementation
The 2011

FY 2011 TASKS
MEDICAID
NOT IN COMPLETED
O IMPPLEMENTATION
STARTED PROGRESS DATE
Jaan. 1, 2011 ISSUE
§2703. STATE PLAN OPTION PROMOTING HEALTH HOMES FOR ENROLLEES WITH CHRRONIC CONDITIONS.
ƒ Creates a neww Medicaid state pllan option under which
w Medicaid enrrollees with at leastt two chronic
conditions or with one chronic condition
c and at rissk of developing annother chronic condition, could
designate a provider as their health home.
ƒ Requires qualifying providers to meet certain standards, including deemonstrating that they have the
systems and infrastructure in plaace to provide com mprehensive and timely high‐quality carec either in‐housse
or by contractting with a team off health professionnals.
ƒ The designateed provider or a teaam of health profeessionals will offer tthe following services: comprehensivve
care managem ment; care coordin nation and health promotion;
p compreehensive transitional care, including
appropriate fo ollow‐up, from inpatient to other settings; patient and ffamily support; and referral to
community an nd social support services, if relevantt and as feasible usse health information technology to liink
such services..
ƒ Teams of provviders could be free‐standing, virtual,, or based at a hospital, community health
h center, clinicc,
physician‘s offfice, or physician group
g practice.
ƒ Directs the staate to develop a mechanism
m to pay thhe health home for services rendered d. The state plan
amendment willw include a plan for f tracking avoidable hospital readm missions and plan foor producing savinggs
resulting from
m improved chronicc care coordination n and managementt.
FEDERAL MATCH PAYYMENTS
ƒ Provides an enhanced match off 90 percent FMAP for two years for sstates that take up this option.
ƒ mall planning grantts may be availablee to help states inteending to take up this
In addition, sm t option. Pre‐
Recovery Act service match ratee.
EVALUATION
ƒ ndependent evaluaation be conducted
Requires an in d after two years to
o assess the impactt of this option on
reducing hosppital admissions.
LEGISLATIVE CONSIDEERATIONS
ƒ Determine paarticipation in statee optional expansio
ons.
ƒ Consider cost‐savings impact.
RESOURCE DOCUMENNTS
ƒ CMS Letter too State Medicaid Directors
D Novembeer 16, 2010
http://www.ccms.gov/smdl/dowwnloads/SMD10024 4.pdf

Na
ational Conferencce of State Legisllatures 33
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICAID
NOT IN COMPLETED
O IMPPLEMENTATION
STARTED PROGRESS DATE
Jaan. 1, 2011 ISSUE [GRANT OPPORTTUNITY]
§2703. STATE PLAN OPTION PROMOTING HEALTH HOMES FOR ENROLLEES WITH CHRRONIC CONDITIONS. [ccontinued]
PLANNING GRANTS
ƒ Authorizes the secretary to award planning grants to states for development of a new plan option,
ƒ Requires a staate match equal to pre‐Recovery Act service match ratee, and authorizes a maximum of $25
million for this purpose.
Jaan. 1, 2011 ISSUE [GRANT OPPORTTUNITY]
§4108. INCENTIVES FOR
F PREVENTION OF CHRONIC DISEASE IN MEDICAID. [PROGRAM
M FOR HEALTHY LIFESTTYLES]
ƒ Creates a gran
nt program for states to provide inceentives to Medicaid
d beneficiaries who
o participate in a
program to deevelop a healthy liffestyle.
ƒ These program ms must be comprehensive and uniquely suited to addrress the needs of Medicaid
M eligible
beneficiaries and
a must have dem monstrated success in helping individ
duals lower or conttrol cholesterol and
d/or
blood pressurre, lose weight, quiit smoking and/or manage
m or preventt diabetes, and maay address co‐
morbidities, such as depression,, associated with th
hese conditions.
ƒ Appropriates $100 million for th
he program for a fivve‐year period.
RESOURCE DOCUMEN
NTS
ƒ SAMHSA Factt Sheet,
http://www.ssamhsa.gov/healthreform/docs/Incen
ntives_Prevention__Chronic_Disease__Medicaid_508.pdff .
January 1, 2011 ISSUE [GRANT OPPORTTUNITY]
publiccation deadline
§2701. ADULT HEALLTH QUALITY MEASURRES.
forr core set of
ƒ Similar to the quality provisions enacted in CHIPRA A, directs the HHS SSecretary, in consu
ultation with the
s
standards
states, to develop an initial set of
o health care quality measures specific to adults who are
a eligible for
Medicaid.
ƒ Establishes th he Medicaid Qualityy Measurement Program which will eexpand upon existing quality measure es,
identify gaps in current quality measurement,
m estaablish priorities forr the development and advancement of
quality measuures and consult wiith relevant stakeh holders.
ƒ Requires the Secretary,
S along with states, to regularly report to Conggress the progress made in identifying
quality measuures and implemen nting them in each state‘s Medicaid p program.
ƒ Standardized reporting by the sttates would begin in 2013.
ƒ States will havve an opportunity to t receive grant funding to support the development, collection,
c and
reporting of quality
q measures.
ƒ Appropriates $60 million for eacch FY 2010 through h 2014. Total fundss available for grants‐$30 million

Na
ational Conferencce of State Legisllatures 34
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

through 2014
4.
FY 2011 TASKS
MEDICARE
NOT IN COMPLETED
O IMPLEMENTATION
STARTED PROGRESS DATE
Jan., 1, 2011 ISSUE
§
§3108. PERMITTING PHYSICIAN ASSISTANTTS TO ORDER POST‐HOSPITAL
O EXTENDED CAARE SERVICES.
ƒ Adds physiciann assistances to thee list of providers authorized
a to orderr (or certify) post‐h
hospital extended care
c
services for Medicare beneficiariies beginning Januaary 1, 2011.
ƒ May impact state dual eligible poopulations.
LEGISLATIVE CONSIDERRATIONS
ƒ Conform as neecessary the state Medicaid
M program criteria for authorrization of post acute extended care with
w
federal law.
Ju
uly 1, 2011 ISSUE
§
§3113. TREATMENT OF
O CERTAIN COMPLEX
X DIAGNOSTIC LABORA
ATORY TESTS.
ƒ Directs HHS to
o conduct a demonstration project un nder part B under w
which separate payyments may be made
for complex diiagnostic laboratorry tests4 to determine the impact on aaccess to and quality of care, health
outcomes, andd expenditures.
ƒ b conducted over a two‐year period beginning July 1, 2011.
The demonstraation project will be 2
ƒ Payments mayy not exceed $100 million.
LEGISLATIVE CONSIDERRATIONS
ƒ Consider impaact on projected staate expenditures fo
or dual eligibles.

4
“compleex diagnostic laboraatory tests’ are deffined as meaning a test: (1)that is an analysis of gene prrotein expression, (2) topographic geenotyping, or a cancer chemotherapy
sensitivityy assay; (3) that is determined
d by the Secretary to be a laboratory test forr which there is nott an alternative tesst having equivalen
nt performance chaaracteristics; (4) whhich
is billed using a Health Care Procedure Codingg System (HCPCS) co ode other than a not
n otherwise classified code under su uch Coding System m; (5) which is approoved or cleared byy
the Food and Drug Administtration or is covereed under title XVIII of the Social Securrity Act; and (6) is described in sectioon 1861(s)(3) of thee Social Security Acct (42 U.S.C.
1395x(s)(3))

Na
ational Conferencce of State Legisllatures 35
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
MEDICARE
NOT IN COMPLETED
O IMPLEMENTATION
STARTED PROGRESS DATE
Jaan. 1, 2011 ISSUE
§
§3114. IMPROVED ACCESS
C FOR CERTIFIED NURSE‐MIDWIFE SERVICES.
ƒ Amends the So ocial Security Act to
o increase coveragge for certified nursse‐midwife services to Medicare
beneficiaries from 80 percent to full coverage as off January 1, 2011.
LEGISLATIVE CONSIDERRATIONS
ƒ Consider impaact on projected staate expenditures fo
or dual eligibles.
Jaan. 1, 2011 ISSUE
§
§3301. MEDICARE COVERAGE
O GAP DISCOU
UNT PROGRAM.
ƒ Effective Januaary 1, 2011, the Disscount Program wiill make manufactu
urer discounts available to applicable
Medicare beneeficiaries receiving applicable coveredd Part D5 drugs wh
hile in the coveragee gap.
ƒ Drug manufactturer will be requirred to provide to Part
P D beneficiariess a 50 percent disco
ount for brand‐nam
me
drugs and biologics at point‐of‐saale.
LEGISLATIVE CONSIDERRATIONS
C
Consider impact onn projected state expenditures
e for du
ual eligibles and Staate Pharmaceutical Assistance
P
Programs.
RESOURCE DOCUMENTS
ƒ CMS memo too plan sponsors Aprril 30, 2010, Mediccare Coverage Gap
p Discount Program
m beginning in 2011
1
https://www.ccms.gov/Prescriptio
onDrugCovContra//Downloads/2011C CoverageGapDiscount_043010v2.pdff
ƒ CMS memo Au ugust 3, 2010,
http://www.cmms.gov/Prescriptio
onDrugCovGenIn/D Downloads/CGDMeemo_08.03.10.pdf
ƒ Medicare.gov: Five Ways to Lowwer Your Costs During The Coverage G
Gap, http://www.mmedicare.gov/health‐
dging‐the‐coveragee‐gap.aspx
and‐drugs/brid
ƒ CMS documen nt: Bridging the Covverage Gap, http:///www.medicare.go
ov/health‐and‐druggs/bridging‐the‐
coverage‐gap.aspx .

5
The Med dicare Prescription
n Drug Benefit was enacted into law on o December 8, 2003 the law re‐desiggns Part D which esstablishes the Volu untary Prescription Drug Benefit
Program. The Part D program is available for in ndividuals who aree entitled to Medicare Part A or enrollled in Medicare Paart B. The Part D prrogram became efffective January 1,
2006. Thee prescription drugg coverage is subjecct to an annual ded
ductible, 25 percen
nt coinsurance up to
t the initial coveraage limit, and the ggreater of $2/$5 orr five‐percent
catastrop
phic coverage for inndividuals that exceeed the annual maximum true out‐off‐pocket threshold..

Na
ational Conferencce of State Legisllatures 36
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
Medicare e
NOT IN COMPLETED
O IMPLEMENTATION
STARTED PROGRESS DATE
Jaan. 1, 2011 ISSUE
§
§4103. MEDICARE COVERAGE
O OF ANNUAL WELLNESS VISIT PRO
OVIDING A PERSONALIZZED PREVENTION PLAN
N.
ƒ Amends the So ocial Security Act to
o require that Med dicare Part B cover once a year, witho
out cost sharing,
6
‘personalized prevention
p plan seervices ,’ including a comprehensive hhealth risk assessm
ment.
LEGISLATIVE CONSIDERRATIONS
ƒ Consider impaact on projected staate expenditures fo
or dual eligibles.
Jaan. 1, 2011 ISSUE
§
§4104. REMOVAL OF BARRIERS TO PREVEN
NTIVE SERVICES IN MEDICARE
E .
ƒ Amends the So ocial Security Act to
o define preventive services covered by Medicare to mean a specified listt of
currently coveered services, includding colorectal can
ncer screening servvices even if diagno
ostic or treatment
services were furnished in conneection with screening
ƒ Waives beneficiary coinsurance requirements
r for most
m preventive services, requiring Medicare
M to cover
osts.
100% of the co
ƒ Specifies that services
s for which no coinsurance woould be required arre the initial preven
ntive physical
examination (IIPPE), personalizedd prevention plan services,
s any additional prevention seervice covered under
the authority of
o HHS, and any currently covered preventive service (in ncluding medical nutrition
n therapy, and
a
excluding electrocardiograms) if it is recommended d with a grade of A or B by the U.S. Prreventive Services
Task Force (USSPSTF)7
LEGISLATIVE CONSIDERRATIONS
ƒ Consider impaact on projected staate expenditures fo
or dual eligibles.
ADDITIONAL RESOURCCE DOCUMENTS
ƒ Agency on Agiing Document: Afffordable Care Act Opportunities
O for tthe Aging Networkk,
http://www.aooa.gov/Aging_Statistics/docs/AoA_Afffordable_Care.pdf .

6
“Personalized prevention plan
p services” meaans the creation of plan for an individual: (1) that includes a health risk asssessment of the ind
dividual that is com
mpleted prior to or
part of the same visit with a health professional; and (2) that takkes into account the results of the heaalth risk assessmen
nt.
7
See the U.S.
U Preventive Servicces Task Force, http:///www.ahrq.gov/clin
nic/uspstfix.htm .

Na
ational Conferencce of State Legisllatures 37
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
Quality, Prevention
P & Wellness
NOT IN COMPLETED
O IMPLEEMENTATION
STARTED PROGRESS DATE
Jan. 1, 2011 ISSU
UE
§30
011. NATIONAL STRATTEGY FOR QUALITY IMPROVEMENT
M IN HEALTTH CARE.
ƒ Directs the secrettary to establish a national
n strategy fo
or quality improvement in healthcaree.
ƒ The secretary mu
ust collaborate with
h state agencies ressponsible for admiinistering the Mediicaid and CHIP
programs with respect to developinng and disseminatinng strategies, goalss, models, and timeetables.
ƒ The deadline for the
t initial submission of the strategy is no later than Jan
nuary 1, 2011.
HEAALTH CARE QUALITY INTERNET WEBSITE
ƒ Directs the secrettary to create an in
nternet website to make public inform
mation regarding th he national priorities
for healthcare quality improvementt, agency specific sttrategic plans, and other pertinent in
nformation the
secretary deems appropriate.
ƒ Implementation must
m be no later th
han January 1, 2011
1.
LEGISLATIVE CONSIDERATTIONS
ƒ Consider the statee needs for dissem
mination of informaation beyond electrronic means.
OURCE DOCUMENTS
RESO
ƒ HHS Proposed Naational Health Care e Quality Strategy and Plan:
http://www.hhs.ggov/news/reports//quality/nationalheealthcarequalitystrrategy.pdf.

Na
ational Conferencce of State Legisllatures 38
The 2011
1 State Legislatorrs’ Check List for Health Reform Implementation

FY 2011 TASKS
STATE EMPPLOYEE BENEFIT CHAN
NGES
NOT IN COMPPLETED IMPLEM
MENTATION
STARTED PROGRESS DATE
Jan.. 2011 ISSU
UE
TITLLE IXREVENUE PROVISIONS.
Impposes various restriictions on tax‐advaantaged accounts which
w are used to p
pay for unreimburssed medical expensses:
heaalth care Flexible Sp
pending Accounts (FSAs),
( Health Reim
mbursement Accou unts (HRAs), Health
h Savings Accounts
(HSAs), and Medical Savings
S Accounts (M
MSAs).
LEGISLATIVE CONSIDERATTIONS
Anaalyze and conform as necessary state
e employee benefiit structures with tthe provisions in the new federal law
w
con
ncerning the follow
wing changes:
ƒ DISTRIBUTION FOR MEDICINE
M QUALIFIED ONLY
O IF FOR PRESCRIBEED DRUG OR INSULIN
§ 9003Staring ini 2011, the PPACA A will prohibit usingg funds from FSA, HHAS, and MSA acco
ounts for over‐the‐‐
counter (OTC) meedications (except insulin) unless theyy are prescribed byy a physician beginning taxable years
after December 31,
3 2010.
ƒ INCREASES IN ADDITIIONAL TAX ON DISTRIBBUTIONS FROM HSAS AND ARCHER MSAS NNOT USED FOR QUALIFFIED MEDICAL EXPENSEES
§ 9004Increasees the penalties imposed for account withdrawals for no onmedical purposees for those under age
65 in two accountts. The penalty for nonmedical withd drawals from HSAs will increase to 20% from 10%, and the t
penalty for nonmmedical withdrawalss from MSAs will in ncrease to 20% from
m 15%.
RESO
OURCE DOCUMENTS
ƒ IRS Document: Saample article for orrganizations to usee to reach customeers and taxpayers
http://www.irs.go
ov/pub/irs‐utl/oc__‐_sept‐mid_aca_cu ust_091710.pdf

Na
ational Conferencce of State Legisllatures 39

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