Federal & State Updates



White House Activity


President Signs Pharmacy “Gag Clause” Bills.  On October 10, President Trump signed into law two separate bills that prohibit pharmacy “gag clauses” in the Medicare program and the commercial health insurance market.

S. 2553, the “Know the Lowest Price Act,” prohibits pharmacy “gag clauses” in the Medicare Part D program.  Specifically, plan sponsors will be required to ensure that the coverage they offer does not restrict a pharmacy from informing an enrollee (or penalize the pharmacy for informing an enrollee) about any differential between the price they would pay for a drug or biological under their health insurance coverage and the price they would pay if they obtain the drug or biological without using any health insurance coverage.

S. 2554, the “Patient Right to Know Drug Prices Act,” prohibits pharmacy “gag clauses” for enrollees covered through group health plans and the individual and group health insurance markets.  This bill also requires settlements between manufacturers of a biologic reference product and a biosimilar product to be submitted to the Federal Trade Commission (FTC) for review when undergoing a Food and Drug Administration (FDA) approval process for the biosimilar product.


Congressional Activity


Senate Activity.  On October 10, the Senate defeated a resolution (S.J.Res. 63) that attempted to block the implementation of the Administration’s final rule on expanding short-term limited duration insurance (STLDI).  The Senate did approve two health-related bills:

 – H.R. 2422, the “Action for Dental Health Act,” would authorize federal grants in two areas: (1) to improve oral health education, prevent dental disease, and reduce barriers to the delivery of dental services; and (2) to support the development of new models for delivering dental services and reduce the use of emergency departments for dental services more appropriately delivered in dental primary care settings.

S. 2465, the “Sickle Cell Disease Research, Surveillance, Prevention, and Treatment Act,” would authorize federal funding to support the treatment and prevention of sickle cell disease.  Other provisions of this bill seek to improve the collection of data on sickle cell disease and support public health strategies to improve health outcomes for patients with this disease.


House Members Express Concern About Use of Prior Authorization in MA Program.  A bipartisan group of House members has addressed a letter to CMS Administrator Seema Verma, expressing concern that “patients may be encountering barriers to timely access to care” due to the use of prior authorization in the MA program.  The letter asks CMS to do the following:


Provide guidance to MA plans regarding the use of prior authorization to ensure that this process does not create inappropriate barriers to care for Medicare patients;

Collect data on the scope of prior authorization practices—including denial, delay, and approval rates;

Provide a report describing CMS oversight of pre-approval policies in MA plans, the use of prior authorization for Part A and Part B services, and audit protocols in this area; and

Engage with key stakeholders on additional opportunities to improve the prior authorization process.


Federal Regulatory Activity



 CMS Announces Information on 2019 Premiums for Plans in Federally-Facilitated Exchange.  On October 11, CMS announced data showing that the average premium for the second-lowest cost silver plans offered in the federally-facilitated Exchange is expected to drop by 1.5 percent in 2019.  CMS also released a table showing state-by-state data on average premiums for both the second-lowest cost silver plans and the lowest cost plans, for a 27-year old single nonsmoker, in the 39 states using the healthcare.gov platform.  Additional findings are discussed in this CMS fact sheet.  Another fact sheet, released by the White House, discusses the President’s policies aimed at expanding coverage options and lowering health insurance premiums.

FDA Issues Guidance to Advance Development of Generic Copies of Complex Drugs.  On October 9, the FDA Commissioner Scott Gottlieb, MD announced the release of two draft guidance documents aimed at advancing the development of generic transdermal and topical delivery systems (TDS).



CMS Announces Participants in New Value-Based Bundled Payment Model.  CMS announced that 1,299 entities have signed agreements with the agency to participate in the Administration’s Bundled Payments for Care Improvement – Advanced (BPCI Advanced) Model. For more information about the BPCI Advanced Model, please visit: https://innovation.cms.gov/initiatives/bpci-advanced.

CMS Releases Information on 2019 MA and Part D Star Ratings.  On October 10, CMS issued a press release and fact sheet showing continued access to high quality coverage choices for Medicare Advantage and Part D plans, based on CMS’ Star Ratings for 2019.

CMS Announces 2019 Premiums and Deductibles for Medicare Parts A and B.  CMS announced information on 2019 premiums and deductibles under the Medicare Part A and Part B programs.



CMS Letter Addresses Details of CHIP Reauthorization.  CMS has addressed a letter to state health officials, discussing key provisions of federal laws, enacted earlier this year, which reauthorize federal funding for CHIP and address other issues affecting children’s health coverage.  The CMS letter provides information on two laws:

H.R. 195, the “HEALTHY KIDS Act,” provided a six-year extension of federal CHIP funding (FY 2018-2023) while also extending various CHIP-related activities through FY 2023.  President Trump signed this legislation into law on January 22, 2018.

H.R. 1892, the “ACCESS Act,” extended federal CHIP funding for four additional years (FY 2024-2027).  President Trump signed this legislation into law on February 9, 2018.


Health Policy Institute (HPIO):

HPIO/Policy Focus Focuses on Approaches to Balance the Healthcare Spending Side of the Health Value Equation.    HPIO will be hosting a forum on August 23 at Nationwide & Ohio Farm Bureau 4-H Center, 2201 Fred Taylor Dr., Ohio State University.  This forum will explore factors that drive high healthcare spending in the U.S. and discuss policy approaches that can impact healthcare spending, with a focus on payment reform, drug prices and investing early in children and prevention.

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.