Health Policy News February 2017

PCG subject matter experts are working hard to keep up with the fast-moving action related to the Affordable Care Act (ACA), Medicaid, Medicare, prescription drug pricing, and other topics under debate at the federal level, as we are sure our readers are as well. Health Policy News seeks to be a source of reliable information for our readers, and, as such, we will do our best to include grounded guidance and timely information regarding the latest developments in federal health policy. In this edition, we focus on significant and substantive developments that may have an impact moving forward.
This month, we also review the final Notice of Benefit and Payment Parameters and Final Letter to Issuers in the Federally-facilitated Marketplaces (Letter) for 2018; the recent Centers for Medicare & Medicaid Services (CMS) approval of Hawaii’s 1332 State Innovation Waiver request, allowing Hawaii to waive certain provisions of the ACA related to the Small Business Health Options Program (SHOP); and the recently released final rules on new Medicare episode payment models (EPMs).
As always, contact us at for more information on any of these topics.

Roundup of federal health policy developments

The debate over the future of the ACA is well-underway in D.C. and there are a number of significant developments to be aware of. Over the past few weeks, President Trump signed an Executive Order on the ACA, three pieces of legislation were introduced in the Senate to repeal and replace the ACA, and the House held hearings on four piecemeal bills that would make incremental changes to the ACA. There are also updates in the House v. Burwell case regarding cost-sharing reduction payments. Click here to read our complete roundup of federal health policy developments.

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CMS issues final 2018 Marketplace guidance

At the same time as debate continues over the future of the ACA, preparations for the next certification period for carriers seeking to offer Qualified Health Plans (QHPs) on Marketplaces must continue. On December 16, 2016, CMS finalized the annual Notice of Benefit and Payment Parameters for 2018 (NBPP) and the 2018 Letter to Issuers on the Federally-facilitated Marketplaces (FFMs). As is typical, the NBPP addresses a breadth of issues relative to health plan regulation as well as Marketplace operations. The Letter provides operational and technical guidance for issuers seeking to offer QHPs and Standalone Dental Plans (SADPs) on FFMs and State-Based Marketplaces on the Federal Platform (SBM-FPs).
PCG’s updated summary of notable changes from prior years’ regulations and guidance is available here.

Our subject matter experts also held a webinar on the final guidance on January 10, 2017, and the slides are available here. Please contact us at if you would like a recording of the webinar.

Continue reading about the recent guidance from CMS here.

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Hawaii receives approval of 1332 State Innovation Waiver

On December 30, 2016, CMS approved the Hawaii 1332 State Innovation Waiver request to opt out of requirements related to the SHOP in order to preserve the state’s Prepaid Health Care Act (Prepaid). The waiver is effective January 1, 2017 through December 31, 2021.

PCG subject matter experts have been examining the use of Section 1332 waivers with state partners for the past few years. Our team published an overview of waiver opportunities under Section 1332 at the end of 2015; and, moving forward under the new administration, we will continue to follow closely the evolving use of 1332 waivers. We are available to answer any questions you may have about provisions of the ACA subject to waiver, limitations, or crafting of 1332 waiver submissions.

Click here to continue reading details of Hawaii’s waiver.

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CMS finalizes rules on episode payment models

On January 3, 2017, CMS published final rules on new Medicare EPMs to be implemented on July 1, 2017. The EPMs are designed to encourage participating hospitals to devise strategies to improve discharge planning, adherence to treatment and medication regimens, and coordination among all providers and suppliers, in order to upgrade quality of care and to reduce overall Medicare spending.

EPMs will include Medicare inpatient hospital stays as well as nearly all care provided under Medicare Part A and Part B within 90 days following hospital discharge. CMS will test EPMs for five performance years beginning July 1, 2017.

Continue reading about the final EPM rules here.

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