Federal & State Updates



CMS Announces Suspension of ACA Risk Adjustment Program for 2017 Plan Year.  On July 7, CMS announced that it is suspending payments for the 2017 plan year under the ACA risk adjustment program, pending the outcome of related litigation.  CMS stated that a recent ruling in the lawsuit New Mexico Connections v. United States Department of Health and Human Services prevents the agency from making further collections or payments under the risk adjustment program, including amounts for the 2017 benefit year, until this litigation is resolved.


On July 9, CMS released the 2017 Risk Adjustment Summary Report providing information on the overall performance of the risk adjustment program and detailed plan-specific information about risk adjustment transfers by state and by market (apparently reflecting the transfers that would be expected absent the decision by CMS to halt such payments). CMS also issued a memorandum providing an overview of recent developments surrounding the risk adjustment program and explaining the agency’s decisions on operational aspects of the program.

On July 12, CMS posted a memorandum providing an overview of recent developments surrounding the ACA risk adjustment program.  The memo discusses pending litigation addressing the risk adjustment program and explains the agency’s decisions on operational aspects of the program. While explaining that CMS is not making collections or payments for the 2017 benefit year at this time, the memo states that the agency “will inform stakeholders of any update to the status of collections or payments at an appropriate future date.”


CMS Announces Funding Reduction for ACA Navigator Program.  On July 10, CMS announced that up to $10 million is available under the Federally-facilitated Exchange (FFE) Navigator Program for plan year 2019. Eligible grantees include chambers of commerce, small businesses, trade associations, and faith-based organizations. This is a significant reduction from the $36 million that was provided for 2018 and the $63 million that was provided for 2017.


ACA Exchange Market

CMS Issues Enrollment Reports on Exchange and Off-Exchange Individual Health Insurance Markets.  CMS recently released three new reports providing information on enrollment in the individual health insurance markets, focusing on activity in both the ACA exchanges and the off-exchange market.

Early 2018 Effectuated Enrollment Snapshot.
This report includes data on effectuated exchange enrollment for 2018 and is similar to effectuated enrollment reports issued in previous years.

Trends in Subsidized and Unsubsidized Enrollment
For this report, CMS analyzed edge server data to quantify enrollment changes in the on and off-exchange individual markets between the 2015-2016 plan years and between the 2016-2017 plan years. This is a new report that has not been issued in the past.

Exchange Trends Report
This is a new report on operational and programmatic aspects of the federally-facilitated marketplace (FFM).


CMS Released an Updated FFE and FF-SHOP Enrollment Manual.  This manual provides operational policy and guidance on key topics related to eligibility and enrollment activities within the FFEs and FF-SHOPs, as well as within the SBE-FPs.


CMS Released the Final 2018 Call Letter and Version 2.0 of 2018 Technical Guidance.  The Final 2018 Call Letter and version 2.0 of the QRS and QHP Enrollee Survey: Technical Guidance for 2018 are now available on the MQI website.



CMS Proposes Changes in Medicare Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program for 2019.  Last week, CMS released a proposed rule that includes updates to payment rates and policies for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.  Comments on this proposed rule are due to CMS on September 10, 2018.


For a fact sheet on the CY 2019 Physician Fee Schedule proposed rule, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12-2.html.

To view the CY 2019 Physician Fee Schedule proposed rule, please visit: https://www.federalregister.gov/public-inspection/.

For a fact sheet on the CY 2019 Quality Payment Program proposed rule, please visit: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-QPP-proposed-rule-fact-sheet.pdf.

To view the CY 2019 Quality Payment Program proposed rule, please visit: https://www.federalregister.gov/public-inspection/.

For a fact sheet on the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12.html.


CMS Proposals to Modernize and Drive Innovation in Durable Medical Equipment and End-Stage Renal Disease Programs.  Last week, CMS proposed changes to the payment rules for Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) and the End-Stage Renal Disease (ESRD) program.

For a fact sheet on the CY 2019 proposed rule (CMS-1691-P), please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-11.html.

To view the proposed rule, please visit: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14986.pdf .



CMS Proposes Rule Change to Protect Medicaid Provider Payments.  Last week, CMS proposed changes to the Medicaid Provider Reassignment regulation that would eliminate state’s ability to divert Medicaid payments away from providers, with the exception of payment arrangements explicitly authorized by statute.   CMS is seeking comments to inform the development of CMS guidance and help explain which payment arrangements would be considered acceptable assignments of Medicaid payments under the current law, especially those between the states and providers.

To view the proposed rule, please visit: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14786.pdf .



1115 Waiver Demonstration – Delaware Diamond State Health Plan Extension Request.  On June 29, 2018, the state of Delaware submitted a request to extend the Delaware Diamond State Health Plan section 1115 demonstration. The state is requesting a five-year extension of the current Diamond State Health Plan demonstration. The state is submitting a separate demonstration amendment request for substance use disorder (SUD) treatment services that, once approved, is requested to be incorporated into this demonstration extension. The state is not requesting any other changes to the demonstration for the extension period at this time, but is in the process of planning for initiatives that reflect the state’s vision for Medicaid and CHIP. These initiatives may necessitate future demonstration amendments.

The federal public comment period will be open from July 13, 2018 through August 12, 2018.

 Pending Application

View/Submit Public Comments

1115 Waiver Demonstration – Delaware Diamond State Health Plan SUD Amendment.  On June 29, 2018, the state of Delaware submitted an amendment to the Delaware Diamond State Health Plan section 1115 demonstration. The state proposes to provide coverage for substance use disorder (SUD) services in settings that qualify as institutions for mental diseases (IMD). The goal of the demonstration amendment is for Delaware to improve outcomes for Medicaid individuals experiencing SUD by maintaining and expanding access to SUD services, including inpatient and residential SUD services in settings that qualify as an IMD, as part of a full continuum of treatment services. The federal public comment period will be open from July 13, 2018 through August 12, 2018.

 Pending Application

View/Submit Public Comments

1115 Waiver Demonstration – Utah Primary Care Network.  On June 21, 2018, the State of Utah submitted an amendment to their section 1115 demonstration, “Primary Care Network.” The state is requesting the authority to (1) add dental benefits for the Targeted Adult Medicaid beneficiaries who are receiving substance use disorder (SUD) treatment; (2) provide family planning services for men and women, ages 19-64, who have incomes at or below 95 percent of the federal poverty level (FPL) and are not otherwise eligible for Medicaid; and (3) provide crisis stabilization services to at-risk Medicaid-eligible children with significant emotional and/or behavioral challenges under the age of 22. The federal comment period will be open from July 12, 2018 through August 11, 2018.

Pending Application

View/Submit Public Comments



Health Policy Institute (HPIO):

Health Policy Institute of Ohio.  The Health Policy Institute of Ohio has released an addendum to its Private Health Insurance Basics series titled “2017 Update: Current policy issues impacting the individual health insurance market in Ohio.”  HPIO released its latest edition of Private Health Insurance Basics as a series of six fact sheets in October 2016.  The new fact sheet serves as an update to the original series, giving policymakers and stakeholders the latest information on the most relevant policy issues related to the individual private health insurance market.  The fact sheet includes information on:

Current and expected trends in premium price increases

ACA marketplace enrollment

Federal state innovation waivers


Health Policy Institute of Ohio.  HPIO’s newly updated healthcare cost and quality data transparency resource page includes federal, state and local-level healthcare cost and quality datasets, tools and reporting, as well as information on organizations setting healthcare quality standards. In 2012, HPIO released its first Health Data Transparency Basics publication which provides an overview of the availability of transparent, accessible health data and discusses how access to information on price and quality impacts consumer choice, quality of care, healthcare spending and health outcomes.  Due to growing interest in the topic, HPIO released a second iteration of the publication in 2016, Healthcare Data Transparency Basics, which explores the rationale for healthcare price transparency, the challenges it presents and potential policy approaches at the state level to increase transparency.

Heath Policy Institute of Ohio – Education, Poverty and Health Presentation to House Task Force.

In a presentation before the House Speaker’s Task Force on Education & Poverty, Health Policy Institute of Ohio staff detailed the correlations between health, income and education, recommending that lawmakers and community stakeholders always view the factors as linked.  Along with the Department of Health and the Governor’s Office of Workforce Transformation, HPIO has made a handful of health-related recommendations that could improve student outcomes.  Among the suggestions are those to incentivize school-based health centers and modify Medicaid rates.

– Gongwer story on the Task Force meeting

– HPIO policy briefs on education


Health Policy Institute of Ohio – Medicaid Basics.

The Health Policy Institute of Ohio has released Ohio Medicaid Basics 2017.  A two-page executive summary is also available.

Guide to Evidence-Based Prevention.  HPIO has added a new fact sheet to its recently updated Guide to Evidence-Based Prevention. The new evidence summary fact sheet highlights evidence-based prevention strategies to increase food security and access to healthy food in Ohio.

The Guide includes a policy brief, Navigating Sources of Evidence, that defines “evidence-based prevention” and provides guidance on how to find credible sources of evidence for what works to prevent Ohio’s greatest health challenges.


Office of Health Transformation:

OHT/Working Together to Fix Healthcare.  Governor John Kasich was a guest on NBC’s Meet the Press where he was talking about the need for both parties in Congress to work together to fix Obamacare.  Watch it here

Office of Health Transformation.  Governor Kasich penned a piece in the New York Times  titled: End the Partisan Warfare on Health Care.  The piece is available at: https://mobile.nytimes.com/2017/03/10/opinion/john-kasich-end-the-partisan-warfare-on-health-care.html

Ohio’s expansion fate in the news. The Columbus Dispatch reported on what may lay ahead for Ohio’s Medicaid expansion. In the story, OHT Director Greg Moody reaffirmed the administration’s intent to preserve Medicaid expansion in the upcoming budget proposal. Read more here.

OHT/Physicians Boost Use of Ohio’s Rx Reporting System.  Governor John R. Kasich has made use of the Ohio Automated Rx Reporting System (OARRS) by prescribers of controlled substances a priority in the fight to reduce abuse of prescription pain medication. The OARRS website used by Ohio doctors, nurses, dentists and pharmacists allows prescribers to track a patient’s opioid prescription history with the goal of stopping drug abuse before it starts. A recent audit conducted by the Ohio Board of Pharmacy found more than 12,000 physicians to be non-compliant with laws enacted in 2015 requiring the use of OARRS. By partnering with the Ohio Medical Board, all 12,000 physicians were urged to make the necessary corrections immediately. As a result, more than 1,800 new accounts have been created in OARRS and daily use of the system has increased from 83,544 requests to over 96,300 per weekday.


Common Sense Initiative:

Common Sense Initiative/Annual Report.  CSI released the 2016 Annual Report of the Common Sense Initiative.

CSI/Business Survey. The Lt. Governor Mary Taylor distributed the following message, which solicits comments and feedback on Ohio’s business and regulatory environment. If interested, I would encourage you to participate in providing feedback. The link and information is below.

Since 2011, Lieutenant Governor Mary Taylor has led Ohio’s Common Sense Initiative (CSI) Office which is intended to promote innovation and common sense regulation of Ohio’s businesses. The Executive Order creating CSI explicitly recognized that Ohio’s business community is a partner in the state’s success, so while regulations play an important role in promoting fair competition and protecting the public, they should do so in a way that also facilitates economic growth and opportunity.

The CSI Office functions as a partnership between the Administration, state agencies, the business community, and the public to develop a regulatory framework that balances the important need for regulation with the equally important need to promote economic opportunity and job creation. It has created a more jobs-friendly regulatory climate in Ohio by independently evaluating the economic impact of state agency regulations on Ohio businesses.

Continued reform and updating of Ohio’s regulations helps Ohio’s economy and job creation by fostering a more business-friendly environment, but we need your help. Below is a link to this year’s CSI business survey. Please take a few minutes to give us your feedback by completing this survey. It should take about 5-7 minutes to complete. Your feedback is important to the success of the CSI Office and will help us identify specific areas where government hinders Ohio’s business community’s ability to create jobs. All responses are anonymous unless you choose to provide your contact information at the end of the survey.

Click the link to start the 2016 CSI Annual Business Survey.


Ohio Department of Medicaid:

Ohio Department of Medicaid and Ohio Department of Mental Health and Addiction Services – Behavioral Health Redesign.  The state Behavioral Health Redesign Benefit and Service Development Work Group met to continue to discuss the implementation of the new billing codes, redesign timeline, and trainings. You can find the information discussed during the meeting at: http://bh.medicaid.ohio.gov/Portals/0/Users/008/08/8/20161130-BSD-Workgroup-Meeting-FINAL.pdf?ver=2016-11-30-115047-323


ODM Medical Care Advisory Committee. The ODM Medical Care Advisory Committee received an update from the Department on the new shared living services that will be made available to individuals receiving services on the PASSPORT and MyCare waivers.  The Shared Living service will provide a live-in caregiver for PASSPORT recipients who need assistance with self-management and the presence of another person (occasional or continuous) in order to assure their health and safety. The Shared Living service includes personal care, chore, individual living assistance and homemaker tasks appropriate to an individual’s needs. The shared living service also assists individuals with managing the household, handling personal affairs, and self-administration of medications.

Dr. Mary Applegate provided the committee with a presentation on ODM’s Managed Care Quality Strategy as well as a briefing on the managed care plan quality improvement projects. Dr. Applegate informed the committee of the new “Transformational Quality Strategy” that shifts the focus to population health. She also provided an update on a number of the quality improvement project success through the Minds Matter project, the OPQC Progesterone Project, and MOMS project (focused on neonatal abstinence).

Dr. Applegate then went on to discuss ODM’s Medicaid managed care plan quality oversight as well as the quality oversight for the MyCare Ohio demonstration. Also discussed was the transformation of the managed care plans care management system, value-based purchasing efforts, and special needs populations.


Ohio Department of Insurance:

Ohio Department of Insurance – Checklist for College Bound kids.

The Ohio Department of Insurance (ODI) created an insurance checklist to help college students and their parents ensure appropriate financial protections are in place for the upcoming school year.

Taylor Steps Down as ODI Director, Froment Takes Over.  Governor Kasich announced that Lieutenant Governor Mary Taylor will step down from her duties as Director of the Ohio Department of Insurance.  Replacing Taylor is Jillian Froment who has served as the agency’s deputy director since 2011.  Taylor remains Lieutenant Governor for the State of Ohio.


ODI/Form, Rate and Binder Filings Training Webinar.  The Ohio Department of Insurance hosted a 2018 Plan Year Major Medical Form, Rate and Binder industry training on March 7, 2017.  The power point presentation used in the training is available at:



Joint Medicaid Oversight Committee:

Joint Medicaid Oversight Committee – Behavioral Health Redesign Update.  JMOC received an update on the State’s Behavioral Health Redesign project from ODM Director Barbara Sears and OMHAS Director Tracy Plouck.  The Directors provided an update on the work to date and highlighted recent policy updates.  Those updates include:

Modifications to allow Qualified Mental Health Specialists with a minimum of 3 years of experience in a relevant field to render MH day treatment;

Updates to the RN/LPN scopes of practice;

Reimbursement updates TBS/PSR;

Training and testing updates.

You can find the presentation at: http://www.jmoc.state.oh.us/meetings.


Joint Medicaid Oversight Committee/2016 Progress Report.  The Joint Medicaid Oversight Committee release its 2016 progress report titled, Slowing Ohio’s Medicaid Per Capita Spending.  The report states that since the creation of JMOC that year over year per capita Medicaid spending has slowed as well as the per member per member spending has been lower than estimated.  Per the report the changes that have been made to the program have saved $1.6 billion across all funds in fiscal years 2015 and 2016 compared to the Executive Budget PMPM estimates.

The report states that a key factor in the savings is the expanded use of managed care as well as increased use of home and community based alternatives.  The report:

acknowledges policies that have increased spending such as provider rate increases, new services and program inflexibility.

– discusses opportunities to lower spending such as behavioral health integration, improved maternal and infant health, and increasing value in health care.

 concludes with a discussion on improving quality through managed care.

calls for JMOC to increase its attention to managed care quality by increasing its review of current initiatives, progress made, and barriers that impeding better results.


You can find the report at: http://www.jmoc.state.oh.us/reports.  JMOC Chairman Burke also issued the following release regarding the report: http://ohiosenate.gov/burke/press/burke-highlights-report-showing-16-billion-in-ohio-medicaid-savings.

Joint Medicaid Oversight Committee. TheJMOC committee reviewed the State Fiscal Years 2018-2019 Biennium Growth Rate Projections report from the committee’s actuary Optumas.  Following the presentation, the committee voted to set the FY2013-2019 growth rate at 3.3%.  This rate is the midpoint between Optumas’s lower and upper bound rates of growth. You can find the presentation and the Optumas report at: http://www.jmoc.state.oh.us/meetings.