The #COVID19 relief bill is finally here, and it includes some interesting ACA provisions...

Well, for good or for bad, it's finally here: The stripped-down-but-bipartisan COVID19 relief bill.

You can read the whole thing here...if you have a LOT of spare time on your hands. It's 5,600 pages long, 1.1 million words. For context, the entire Lord of the Rings trilogy is only half that length (576,000 words).

There's 1,000 explainers being written today about the most obvious stuff (the $600 direct relief checks, the extended & enhanced unemployment funding, etc etc), most of which falls far short of what's actually needed. Instead, I'm focusing on the ACA-related provisions. I already wrote about the surprise billing prohibition this morning, of course, but a quick initial scan of the text (which isn't easy...again, 5,600 pages...) reveals several other items directly related to the Affordable Care Act, so let's take a look! (Note: I'm sure I'm missing a few):

Page 4,206:

SEC. 226. (a) The Secretary shall provide to the Committees on Appropriations of the House of Representatives and the Senate:

(1) Detailed monthly enrollment figures from the Exchanges established under the Patient Protection and Affordable Care Act of 2010 pertaining to enrollments during the open enrollment period;

The first part of this got me very excited as a data nerd. Right now, the Centers for Medicare & Medicaid (CMS) generally only provide detailed enrollment figures for the annual Open Enrollment Period (OEP) as a whole in the spring (usually late March/early April), and while this is fairly detailed and reasonably useful, it's limited to the 7-week OEP itself (plus the extended OEPs for some state-based exchanges).

Aside from that report, CMS also issues the weekly "snapshot reports" for HC.gov states only during OEP, plus one or two Effectuation Reports later in the year. I'd love to have data as detailed as the annual OEP report for all 50 states +DC for all twelve months of the year!

Unfortunately, the second part of the sentence makes it sound like this is limited to OEP itself...which we already have. I mean, if the Biden Administration extends OEP back out to 3 full months again (which seems likely), I supposed we'd have 3 monthly reports instead of a single one for all 3 months, which is good, but that's not much to cheer about.

What I'd really like to see is detailed weekly reports (not just the snapshots) during OEP and detailed monthly reports year-round, including Special Enrollment Period (SEP) enrollments and disenrollments each month throughout the year to track retention/attrition patterns across every state + DC.

Pages 4,207:

(2) APPLICATION TO GRANDFATHERED PLANS.—Section 1251(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18011(a)) is amended by adding at the end the following:

‘‘(5) APPLICATION OF ADDITIONAL PROVISIONS.—Sections 2799A–1, 2799A–2, and 2799A–7 of the Public Health Service Act shall apply to grandfathered health plans for plan years beginning on or after January 1, 2022.’’.

From what I can tell, it sounds like this means that the Surprise Billing prohibition I wrote about this morning will also apply to "grandfathered" individual & small group market policies still around from before the ACA was enacted (though there's probably only a few hundred thousand people still enrolled in these).

Pages 4,605 - 4,606:

SEC. 103. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME PROGRAMS.

(a) STATE HEALTH INSURANCE PROGRAMS.—Subsection (a)(1)(B) of section 119 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 9 1395b–3 note), as amended by section 3306 of the Patient Protection and Affordable Care Act (Public Law 111– 11 148), section 610 of the American Taxpayer Relief Act of 2012 (Public Law 112–240), section 1110 of the Pathway for SGR Reform Act of 2013 (Public Law 113–67), section 110 of the Protecting Access to Medicare Act of 2014 (Public Law 113–93), section 208 of the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10), section 50207 of division E of the Bipartisan Budget Act of 2018 (Public Law 115–123), section 1402 of division B of the Continuing Appropriations Act, 20 2020, and Health Extenders Act of 2019 (Public Law 116–59), section 1402 of division B of the Further Continuing Appropriations Act, 2020, and Further Health Extenders Act of 2019 (Public Law 116–69), section 103 of division N of the Further Consolidated Appropriations Act, 2020 (Public Law 116–94), section 3803 of the CARES Act (Public Law 116–136), section 2203 of the Continuing Appropriations Act, 2021 and Other Extensions Act (Public Law 116–159), and section 1102 of the Further Continuing Appropriations Act, 2021, and Other Extensions Act, is amended—

(1) in clause (x), by striking at the end ‘‘and’’; and

(2) by striking clause (xi) and inserting the following clauses:

‘‘(xi) for fiscal year 2021, $15,000,000; ‘‘(xii) for fiscal year 2022, $15,000,000; and ‘‘(xiii) for fiscal year 2023, 15 $15,000,000.’’.

I'm not entirely sure, but it sounds like this basically provides $15 million per year to states to help fund education/outreach for various state-level health insurance programs...though I'm not sure which programs those include.

Page 4,721:

SEC. 205. EXTENSION OF SPOUSAL IMPOVERISHMENT PROTECTIONS.

(a) IN GENERAL.—Section 2404 of the Patient Protection and Affordable Care Act (42 U.S.C. 1396r-5 note) is amended by striking ‘‘December 18, 2020’’ and inserting ‘‘September 30, 2023’’.

I checked out Section 2404 of the original PPACA:

During the 5-year period that begins on January 1, 2014, section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 1396r-5(h)(1)(A)) shall be applied as though ``is eligible for medical assistance for home and community-based services provided under subsection (c), (d), or (i) of section 1915, under a waiver approved under section 1115, or who is eligible for such medical assistance by reason of being determined eligible under section 1902(a)(10)(C) or by reason of section 1902(f) or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care, or who is eligible for medical assistance for home and community-based attendant services and supports under section 1915(k)'' were substituted in such section for ``(at the option of the State) is described in section 1902(a)(10)(A)(ii)(VI)''.

I wasn't familiar with "Spousal Impoverishment" (it sounds like a domestic abuse type of thing), so I checked it out as well:

The expense of nursing home care — which ranges from $5,000 to $8,000 a month or more — can rapidly deplete the lifetime savings of elderly couples. In 1988, Congress enacted provisions to prevent what has come to be called "spousal impoverishment," leaving the spouse who is still living at home in the community with little or no income or resources. These provisions help ensure that this situation will not occur and that community spouses are able to live out their lives with independence and dignity.

Under the Medicaid spousal impoverishment provisions, a certain amount of the couple's combined resources is protected for the spouse living in the community. Depending on how much of his or her own income the community spouse actually has, a certain amount of income belonging to the spouse in the institution can also be set aside for the community spouse's use.

It sounds like the original ACA cut this off at the end of 2018 (?), but it had been previously bumped out by 2 years and is now being extended by 3 more (?). Why it would have an expiration date in the first place I don't know, but I'm probably misunderstanding something here.

Page 4,554:

SEC. 301. EXTENSION FOR COMMUNITY HEALTH CENTERS, THE NATIONAL HEALTH SERVICE CORPS, 6 AND TEACHING HEALTH CENTERS THAT OPERATE GME PROGRAMS.

(a) COMMUNITY HEALTH CENTERS.—Section 9 10503(b)(1)(F) of the Patient Protection and Affordable Care Act (42 U.S.C. 254b–2(b)(1)(F)) is amended by striking ‘‘, $4,000,000,000 for fiscal year 2019, $4,000,000,000 for fiscal year 2020, and $865,753,425 for the period beginning on October 1, 2020, and ending on December 18, 2020’’ and inserting ‘‘and $4,000,000,000 for each of fiscal years 2019 through 2023’’.

(b) NATIONAL HEALTH SERVICE CORPS.—Section 10503(b)(2)(H) of the Patient Protection and Affordable Care Act (42 U.S.C. 254b–2(b)(2)(H)) is amended by striking ‘‘ $67,095,890 for the period beginning on October 1, 2020, and ending on December 18, 2020’’ and in22 serting ‘‘ $310,000,000 for each of fiscal years 2021 23 through 2023’’.

I've only written about Community Health Centers a couple of times before, usually when their funding was at risk of expiring:

Since the nation’s first health centers opened in 1965, expansion of the federally-supported health center system to over 1,400 organizations has created an affordable health care option for more than 28 million people. Health centers help increase access to crucial primary care by reducing barriers such as cost, lack of insurance, distance, and language for their patients. In doing so, health centers provide substantial benefits to the country and its health care system.

Health centers:

  • Provide highly efficient and cost-effective care, generating $24 billion in savings for the health care system annually.
  • Increase access to timely primary care, playing a role in reducing costly, avoidable emergency department (ED) visits and hospital stays. The average cost for a health center medical visit was less than one-sixth the average cost of an ED visit in 2012.
  • Deliver a broad array of primary and preventive care services, including screening, diagnosis and management of chronic illnesses such as diabetes, asthma, heart and lung disease, depression, cancer and HIV/AIDS.
  • Reduce mortality, health disparities and risk of low birth weight with the care they deliver.
  • Offer numerous enabling services such as transportation, translation, case management and health education in order to ensure their patients are receiving the care they need.

Beefing up the funding of CHCs was Bernie Sanders' baby during the original 2009-2010 ACA negotiations, but funding sunsets and has to be renewed every few years. It sounds like the latest round of funding actually expired 3 days ago but would be bumped out for another three years. Oddly, the start date refers to fiscal year 2019 instead of fiscal year 2020, so I'm not sure what the deal is there...perhaps some of the funding for 2019 was borrwed from another agency or something?

As for the National Health Service Corps:

The National Health Service Corps (NHSC) is a Federal program administered by the Health Resources and Services Administration (HRSA) that provides scholarships and loan repayment to healthcare professionals practicing at approved sites located in/or serving Health Professional Shortage Areas (HPSAs) throughout the United States. Students or providers interested in receiving scholarship or loan repayment through the NHSC should contact the NHSC directly at (800) 221-9393 for more information or nhsc.hrsa.gov.

A health facility that is interested in hiring NHSC Scholars and Loan Repayers must submit an application to become an approved NHSC site. Your facility may be eligible to become an NHSC-approved site if it:

  • Is located in a Health Professional Shortage Area (HPSA)
  • Provides primary care medical, dental, or behavioral health services
  • Provides services regardless of a patient’s ability to pay
  • Offers discounted fees to patients who qualify
  • Accepts patients covered by Medicare and Medicaid

Short version: Think Northern Exposure or Doc Hollywood, if you're old enough to remember that TV show or movie, except as an official federal program. Apparently the bill will provide $310 million/year to keep funding for this program chugging along.

Pages 4489 - 4490:

‘‘SEC. 2746. DISCLOSURE TO ENROLLEES OF INDIVIDUAL MARKET COVERAGE.

‘‘(a) IN GENERAL.—A health insurance issuer offering individual health insurance coverage or a health insurance issuer offering short-term limited duration insurance coverage shall make disclosures to enrollees in such coverage, as described in subsection (b), and reports to the Secretary, as described in subsection (c), regarding direct or indirect compensation provided by the issuer to an agent or broker associated with enrolling individuals in such coverage.

‘‘(b) DISCLOSURE.—A health insurance issuer described in subsection (a) shall disclose to an enrollee the amount of direct or indirect compensation provided to an agent or broker for services provided by such agent or broker associated with plan selection and enrollment. Such disclosure shall be—

‘‘(1) made prior to the individual finalizing plan selection; and

‘‘(2) included on any documentation confirming the individual’s enrollment.

‘‘(c) REPORTING.—A health insurance issuer described in subsection (a) shall annually report to the Secretary, prior to the beginning of open enrollment, any direct or indirect compensation provided to an agent or broker associated with enrolling individuals in such coverage.

‘‘(d) RULEMAKING.—Not later than 1 year after the date of enactment of the Consolidated Appropriations Act, 2021, the Secretary shall finalize, through notice-and-comment rulemaking, the timing, form, and manner in which issuers described in subsection (a) are required to make the disclosures described in subsection (b) and the reports described in subsection (c). Such rulemaking may also include adjustments to notice requirements to reflect the different processes for plan renewals, in order to provide enrollees with full, timely information.’’.

(d) TRANSITION RULE.—No contract executed prior to the effective date described in subsection (e) by a group health plan subject to the requirements of section 408(b)(2)(B) of the Employee Retirement Income Security Act of 1974 (as amended by subsection (a)) or by a health insurance issuer subject to the requirements of section 2746 of the Public Health Service Act (as added by subsection (c)) shall be subject to the requirements of such section 408(b)(2)(B) or such section 2746, as applicable.

(e) APPLICATION.—The amendments made by subsections (a) and (c) shall apply beginning 1 year after the date of enactment of this Act.

Regular readers know that I've railed against #ShortAssPlans for years...while simultaneously accepting them as a necessary evil until the ACA's subsidy cliff is eliminated (for the. short term, one might say). This section wouldn't ban #ShortAssPlans, but it would at least require them to let enrollees and the HHS Secretary know, prominently and before anyone actually signs up, just what portion of the premiums they're paying are going to insurance brokers in the form of commissions or other types of compensation.

Interestingly, it would also require commission/compensation disclosure be made for ACA-compliant health insurance policies as well, which apparently isn't currently required at the federal level.

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I'm sure there are other ACA-related sections buried in the bill, but these are the ones which I've been able to find so far. Feel free to let me know if you find any others...

UPDATE: Via an email from the House Energy & Commerce Committee, the bill also includes several other healthcare-related provisions which aren't all necessarily ACA-specific but are important nonetheless:

  • Delivers $69 billion in critically needed funding for COVID-19 testing, contact tracing, vaccines, mental health, and support for health care providers. Included in this funding is $22 billion for testing, contact tracing, surveillance and mitigation, $19 billion for vaccines and therapeutics, including the manufacture, production, and purchase of vaccines, therapeutics and ancillary supplies, and nearly $9 billion in additional funding to support distribution of lifesaving COVID-19 vaccines that will help bring an end to the pandemic.

(OK, this one was kind of obvious given the main thrust of the legislation...)

  • Authorizes a national campaign to increase awareness and knowledge of the safety and effectiveness of vaccines, for the prevention and control of diseases and to combat misinformation and offers support to expand, enhance, and improve public health data collection.

(Again, kind of a no-brainer.)

  • Provides long-term extensions of expiring public health programs, including: Community Health Centers, the National Health Service Corps, Teaching Health Centers, and Special Diabetes Programs.

I mentioned the first two above; I'm less familiar with the second two.

  • Waives Medicare coinsurance for certain colorectal cancer screening tests. This provision gradually eliminates cost-sharing for Medicare beneficiaries with respect to colorectal cancer screening tests, even in cases where a polyp is detected and removed.

Nothing specifically tied to the ACA or COVID, really, but a good thing to strengthen Medicare.

  • Restores Medicaid eligibility for citizens of the Freely Associated States (the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau) lawfully residing in the United States under the Compacts of Free Association.

This is a big deal which Politico reporter Dan Diamond has done some fantastic writing on; I'll post a separate blog entry about that tomorrow.

  • Eliminates Medicaid Disproportionate Share Hospital (DSH) cuts until fiscal year 2024.

I don't know too much about this, but it sounds like it basically refers to extra payments states have to pay to hospitals which have an unusually high number of Medicaid or uninsured patients since they tend to come up short on funding for obvious reasons (Medicaid doesn't pay hospitals nearly as much as private insurance and the uninsured usually can't pay at all).

  • Extends critical programs including the Medicaid demonstration to expand access to certified community behavioral health clinics, protections against spousal impoverishment for partners of Medicaid beneficiaries receiving home- and community-based services, and the Money Follows the Person rebalancing demonstration.

I wrote about the "spousal impoverishment" item above. I'm not familiar with the other two.

Here's the description of Certified Community Behavorial Health Clinics:

These entities, a new provider type in Medicaid, are designed to provide a comprehensive range of mental health and substance use disorder services to vulnerable individuals. In return, CCBHCs receive an enhanced Medicaid reimbursement rate based on their anticipated costs of expanding services to meet the needs of these complex populations.

CCBHCs are responsible for directly providing (or contracting with partner organizations to provide) nine types of services, with an emphasis on the provision of 24-hour crisis care, utilization of evidence-based practices, care coordination and integration with physical health care. The demonstration program represents the largest investment in mental health and addiction care in generations.

Here's the description of "Money Follows the Person:"

...the Money Follows the Person (MFP) demonstration supports state efforts for rebalancing their long-term services and supports system so that individuals have a choice of where they live and receive services. From the start of the program in 2008 through the end of 2019, states have transitioned 101,540 people to community living under MFP.

MFP Program Goals

  • Increase the use of home and community-based services (HCBS) and reduce the use of institutionally-based services
  • Eliminate barriers in state law, state Medicaid plans, and state budgets that restrict the use of Medicaid funds to enable Medicaid-eligible individuals to receive support for appropriate and necessary long-term services and supports in the settings of their choice
  • Strengthen the ability of Medicaid programs to provide HCBS to people who choose to transition out of institutions
  • Put procedures in place to provide quality assurance and improve HCBS