Tag: news

Q&A: Implications of the Ruling on the ACA’s Preventive Services Requirement

Note: This post was updated on April 4, 2023, to include additional details and a table showing potentially affected preventive services.

On March 30, 2023, a judge in the U.S. District Court in the Northern District of Texas issued a final judgment in a court case challenging the provision of the Affordable Care Act (ACA) that requires most private health plans to cover a range of preventive services without any cost-sharing for their enrollees. Having concluded in September that aspects of the requirement were unconstitutional and violated religious rights, the judge’s remedy in the Braidwood Management v. Becerra imposes new limits on the government’s ability to enforce those requirements nationwide. This Q&A summarizes some of the key issues related to the ruling.

What does the ruling mean for the public?

With about 100 million privately insured people using preventive services required by the ACA to be covered without out-of-pocket costs, the preventive services coverage requirement is the provision of the ACA that affects the broadest number of people, and it has been enormously popular with the public. Because of the ACA requirement, the vast majority of private health plans have to cover a range of preventive services and cannot impose deductibles or copays for them. If the ruling stands, over time, millions of people could end up paying more for preventive care and some may lose access to certain services. However, as sweeping as the ruling is, it does not completely and immediately wipe out preventive services coverage under the ACA.

That’s because the ruling applies specifically to services recommended by the US Preventive Services Taskforce (USPSTF) that were made after 2010 when the ACA was enacted. The ruling would not overturn coverage requirements for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), women’s preventive health services (such as contraception, well women care and prenatal care, breastfeeding support services, and intimate partner violence screening) recommended by the Health Resources and Services Administration (HRSA),  or services for children and young adults recommended by Bright Futures, though the plaintiffs had asked that those be struck down as well and that decision could be appealed. The ruling also only applies to updates to or new USPSTF recommendations issued since March 2010, when the ACA was enacted. It would effectively lock in place coverage requirements based on evidence from 13 years ago.

The ruling separately finds that the mandate to cover pre-exposure prophylaxis (PrEP), a medication taken to prevent HIV, violates the plaintiffs’ religious rights under the Religious Freedom Restoration Act (RFRA). While the RFRA remedy is limited specifically to the plaintiffs, because PrEP was recommended by the USPSTF after 2010, the medication and certain ancillary lab services can now be subject to out-of-pocket costs across all health plans and plans could elect to drop coverage altogether.

Coverage will not necessarily change immediately. Although the ruling is effective immediately, in many cases, health plan contracts are in place for the calendar year, and employers do not typically make changes to coverage or cost midyear. (It may be easier for plans to change formularies to allow for cost-sharing with respect to impacted drugs.)

Read the full article with details about changes at KFF.

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Quick Guide to Recent Changes to Medicare

The Consolidated Appropriations Act (CAA) and the Inflation Reduction Act (IRA) improve program benefits, clarify enrollment rules, eliminate coverage gaps, and strengthen the program for the estimated 64.5 million Americans who have Medicare health care coverage. These changes to Medicare provide important protections and strengthen the program, but navigating the changes can be complicated. To help the aging and disability networks who are fielding questions and making sure that the people they serve are aware of these changes, this blog post provides an overview of the changes that are most important for older adults and people with disabilities to be aware of. For people who need additional help, ACL’s State Health Insurance Assistance Program (SHIP) offers one-on-one assistance, counseling, and education to Medicare beneficiaries, their families, and caregivers to help them make informed decisions about their care and benefits.

CAA Medicare Provisions

The CAA revised key Medicare enrollment rules and timelines for coverage to become effective. It also extended limited eligibility to cover immunosuppressive drugs for kidney transplant patients under age 65.

Key Medicare Enrollment Rules

Most people (88%) qualify for Medicare when they celebrate their 65th birthday. The remaining 12% qualify due to disability.

Most people who qualify based on age need to enroll in Medicare when they turn 65, even if they have other health insurance. People can defer enrollment in a few situations. For example, if they (or their spouse) are still working for an employer that has 20 or more employees and have health insurance through that employer, they can wait to enroll in Medicare until they are not.

People who do not apply when they are first eligible usually have to wait until the next open enrollment period to get coverage. In addition, most will have to pay higher premiums — forever — if they enroll late.

People who receive Social Security retirement or disability benefits (or Railroad Retirement benefits) are automatically enrolled in Medicare when they become eligible, but everyone else needs to apply. Unfortunately, many people do not understand this, or mistakenly believe they qualify for delayed enrollment, and they do not enroll when they should.

Read the full article from the Administration for Community Living.

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Executive Order Expands Access to Community Living Services, Supports Family Caregivers

On April 18, 2023, President Biden will sign an executive order (EO) that includes more than 50 directives to federal agencies to increase access to affordable, high-quality care, and provide support for care workers and family caregivers.

The EO directs actions to improve job quality for the professionals who provide the critical services that make community living possible for millions of people. It includes actions to improve support for the 53 million family caregivers who provide the overwhelming majority of long-term support to older adults and people with disabilities. It also directs actions to expand availability of home and community-based services, including those funded by Medicaid and the Department of Veterans Affairs.

This exciting EO creates new momentum for ACL’s work to strengthen the care infrastructure that helps people with disabilities and older adults live and fully participate in their communities, including our work leading the National Strategy to Support Family Caregivers and to strengthen and expand the direct care workforce, our partnership with the Veterans Health Administration on the Veteran-Directed Care program, and more.

This White House fact sheet has more of the highlights. (We will share a link to the full text of the EO on our social channels and on ACL.gov as soon as it is available.)

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Medicare Advantage Special Needs Plans for dual eligible (Medicare and Medicaid) clients

Medicare Advantage Special Needs Plans are available to clients who are eligible for Medicare and Medicaid (dual eligible). Special Needs Plans provide additional benefits to clients beyond what traditional Medicare and Medicaid provide including, but not limited to, care coordination, gym memberships, transportation to medical appointments and meal delivery.

Click the below link to learn more.

dual-eligible-special-needs-plan

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Teen Health Crisis

Adolescent Mental Health & Wellbeing

A new CDC report points to record levels of violence, trauma, and mental health concerns for teenagers, with girls and LGBQ+ youth faring more poorly (the survey did not ask about transgender identity). The findings highlight how the pandemic made things worse for many kids.

  • Violence: Violence puts adolescent lives at risk and can lead to mental health problems, risky behavior, and reduced academic success. The CDC report contains data on violence among high schoolers, including sexual violence, feeling unsafe at school, bullying, and cyberbullying.
  • Technology: High use of social media is associated with mental health problems. Social media impacts how teens interact with one another during a developmentally important time in life. According to new research, limiting social media usage can make teens feel better about their body image.
  • Supporting Mental Health: Young people who identify as LGBTQ+ are less likely to feel depressed with parental support. Additionally, public schools and states are taking steps to expand access to mental health services.

Read more at NIHCM.

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COVID-19 Public Health Emergency to End on May 11

Since January 2022, daily COVID-19 reported cases are down 92%, COVID-19 deaths have declined by over 80%, and new COVID-19 hospitalizations are down nearly 80%.

As a result, the U.S. Department of Health and Human Services (HHS) announced that the COVID-19 Public Health Emergency (PHE) will end on May 11. To prepare for this transition, HHS has released Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap detailing what will and will not be affected by the end of the PHE.

For provider-specific information about PHE waivers and flexibilities, visit the Centers for Medicare & Medicaid Services (CMS) Emergencies webpage.

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Suicide Among People with Disabilities

We may make assumptions about people with disabilities’ risk for suicide. A 2021 report published in the American Journal of Preventive Medicine found people with disabilities are more likely to think about, plan or attempt suicide than people without disabilities.

Please click the link below to learn more about:

  • Risk factors.
  • What you can do as a caregiver.
  • What to look for.
  • When to get help.

To see all other Care Provider Bulletins click here.

Suicide Among People with Disabilities

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Feds Move to Rein In Prior Authorization, a System That Harms and Frustrates Patients

When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.

As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

“On at least four or five occasions, she called me up, hysterical,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.

Read the full article from KHN.

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Medicare’s Mental Health Coverage: What’s Included, What’s Changed, and What Gaps Remain

How prevalent are mental health issues among Medicare beneficiaries?

About one in four Medicare beneficiaries live with mental illness — conditions such as depression, anxiety, schizophrenia, and bipolar disorder — but only 40 percent to 50 percent receive treatment.1 The prevalence of mental illness is about equal among beneficiaries enrolled in traditional Medicare (31%) and those in Medicare Advantage plans (28%), although variation in data sources and measurement make comparisons difficult.2

Mental illness is experienced most by those beneficiaries under age 65 who qualify for Medicare via disability, as well as by low-income beneficiaries dually eligible for Medicare and Medicaid.3 It is also more pervasive in beneficiaries from American Indian/Alaska Native and Hispanic communities relative to other racial and ethnic groups.4

Which mental health services does Medicare cover?

Medicare covers both outpatient and inpatient services as well as prescription drugs to treat mental illness.5 Traditional Medicare and Medicare Advantage plans generally follow the same coverage rules, and some also cover additional services, like grief counseling, or offer other tailored benefits through special needs plans catering to beneficiaries with mental illness.6

Inpatient services. Medicare Part A covers inpatient mental health services in both general hospitals and psychiatric hospitals, but the latter is limited to 190 total days per beneficiary across their lifetime. Traditional Medicare beneficiaries pay a deductible and coinsurance for each benefit period, which, for hospital services, begins on the day of admission and ends after a beneficiary has had no inpatient care for 60 consecutive days. Cost-sharing requirements vary across plans for Medicare Advantage enrollees.

Outpatient services. Medicare Part B covers outpatient mental health services delivered by psychiatrists or other physicians, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. The services covered include standard services like psychiatric evaluation, individual and group therapy, and medication management. After paying their annual deductible, traditional Medicare beneficiaries pay 20 percent of the Medicare-approved amount for covered services. As with inpatient services, cost-sharing requirements vary across Medicare Advantage plans.

Medication. For traditional Medicare beneficiaries, mental health medications are covered by Medicare Part D. Beneficiaries in a Medicare Advantage plan also may have a Part D prescription drug plan or another drug plan that follows Part D rules. All Medicare drug plans are required to cover antidepressant, anticonvulsant, and antipsychotic medications, as well as a wide range of other psychotropic medications like anti-anxiety drugs. Specific medications covered and out-of-pocket costs vary by drug plan.

Read the full article from the Commonwealth Fund.

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Long COVID: What We Know

Mild to moderate COVID-19 lasts about two weeks for most people. In others, the long-term effects of COVID-19 can cause lingering health problems that last for months. While it is clear that people with certain risk factors like high blood pressure, smoking, diabetes, and obesity are more likely to have a serious case of COVID-19, there is not a clear link between these risk factors and the long-term effects of COVID-19. While the percentage of people who have had COVID and currently report long COVID symptoms has recently declined, the rate remains high.

This infographic explores what we currently know about long COVID. It also offers methods for preventing long COVID through protective measures and vaccines. Although we still do not know much about long COVID, scientists are working to better understand this new and emerging illness and how different groups of people experience it.

For more information, visit NIHCM.

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