MHA CEO Report — A Healthy Michigan is an Insured Michigan

MHA Rounds Report - Brian Peters, MHA CEO

“Life is what happens while you are busy making other plans.” — John Lennon

MHA Rounds Report - Brian Peters, MHA CEOThe United States celebrated last month the 13th anniversary of the signing of the Affordable Care Act (ACA). Simply put, when then-President Obama signed the legislation March 23, 2010, it was one of the most monumental healthcare policy changes in our lifetime. Since its passage, it has provided millions of Americans with health insurance, provided access to care for millions of residents with preexisting conditions and incentivized the launch of innovative models of care that have improved patients’ lives and saved billions of healthcare dollars.

The MHA was pleased to celebrate the anniversary by having MHA Executive Vice President Laura Appel join U.S. Rep. Elissa Slotkin and others in a virtual press conference discussing the positive impact the ACA has had on Michiganders.

The mission of the MHA is to “advance the health of individuals and communities.”  We have long supported the ACA, as the availability of robust health insurance coverage is crucial to achieving this mission. The benefits of the ACA can be measured by the more than one million Michiganders now covered by our Medicaid expansion program – the Healthy Michigan Plan – and more than 320,000 Michiganders who now receive coverage through the Health Insurance Marketplace created simultaneously by the act. Combined, these new developments have helped to significantly reduce the number of uninsured individuals in Michigan, which consistently numbered well over one million people in the years prior to the ACA’s passage.

The history of health insurance coverage in America is interesting and complex, and there were two major turning points in the 20th century that preceded the ACA. First, to combat inflation amid World War II, Congress passed the 1942 Stabilization Act. Designed to limit the ability to raise wages, the act led employers to instead offer health benefits for the very first time. Because health benefits did not count as income, they were not taxable to the employees. With a flip of the proverbial switch, employers were in the health insurance business and have never looked back. Second, in 1965 then-President Lyndon B. Johnson signed into law the enabling legislation to create the Medicare and Medicaid programs, which have provided coverage to important populations including seniors, those with disabilities, low-income and more.

Today the majority of Michiganders – over six million – are covered by employer-sponsored private insurance. But both Medicare and Medicaid have grown, accounting for approximately two million enrollees in each program respectively.  This growth is driven by different factors: for Medicare, we obviously have an aging population, increasingly fueled by the baby-boom generation. And for Medicaid, we have seen both organic growth in the traditional program, as well as significant growth in the Medicaid expansion program.

Whether public or private, we celebrate health insurance coverage because it directly benefits people, as they are more likely to see a primary care practitioner, seek recommended tests and screenings, receive appropriate prenatal care and generally access a wide array of healthcare services in such a way that their issues can be identified and resolved as early as possible. Not only does this mean better outcomes, but it also saves healthcare costs in the long run. And of course, having insurance coverage provides financial peace of mind for families when an unanticipated serious illness or catastrophic injury occurs.

The truth is that better insurance coverage is a positive for hospitals as well, as it helps to reduce the amount of uncompensated care that we must absorb. However, simply having an insurance card is no guarantee that an individual will have the appropriate level of coverage, as the rise in high-deductible and “skinny” insurance plans still result in significant and growing out-of-pocket expenses for consumers. These plans in turn have created more bad debt and uncompensated care for hospitals because consumers often purchase these plans based strictly on price without full knowledge of their co-pays, deductibles, which providers are considered in-network and what care may not be covered at all. On this note, the subject of surprise medical bills has been in the spotlight in recent years, culminating with the implementation of the federal No Surprises Act in January 2022. There is no doubt hospitals own our share of this issue – and we are committed to doing all we can to improve. But as a wise health policy observer commented to me at the time, the situation for far too many Americans can be summarized as “surprise, your health insurance stinks.” The total unpaid costs of patient care for Michigan hospitals in 2020 exceeded $3.4 billion, and the anecdotal evidence points to this challenge continuing ever since.

Back to the public policy front, one key issue on our radar screen now is the pending expiration of the COVID-19 public health emergency (PHE). Michigan has an additional 355,000 residents enrolled in traditional Medicaid and 367,000 additional Healthy Michigan Plan enrollees since the PHE began, and many of them will be at risk of losing coverage when the PHE ends and the Medicaid “redetermination” process begins.

In many Michigan counties, more than 30% of the population uses Medicaid for its healthcare benefit. The goal of the MHA and our partner stakeholder groups is to work with the Michigan Department of Health and Human Services (MDHHS) to ensure as many people as possible either maintain their Medicaid coverage or transition to an appropriate plan on the insurance exchange if they do not now have employer-sponsored coverage. This will continue to ensure that community members avoid interruptions in their care and will allow us to maintain many of the health outcome gains achieved over the past 13 years.

The MDHHS has created tools and resources for providers and partners aimed at educating their patients about the need to ensure their contact information is updated so they properly process their redetermination paperwork. The MHA has worked closely with our member hospitals and health systems to share these resources. This may be the first time for many beneficiaries that they must renew their coverage, and some may not even be aware they’re on Medicaid. Hospitals are the main touchpoint for many beneficiaries and hence play a very significant role in helping to facilitate this process for vulnerable patients.

The ACA, like any other major public policy change, has been far from perfect. But reflecting on the success in providing coverage to more Michiganders, we must express our gratitude for those at both the federal and state levels for the gains we’ve made over the past 13 years. In Michigan, we’ve received bipartisan support over the years for expanded coverage. Despite all the challenges hospitals and health systems have experienced in recent years, the gains made from the ACA have been a big reason why Michigan hospitals can continue to serve their communities throughout all areas of the state.

And on the broader issue of health insurance coverage, we would be remiss if we did not acknowledge that insurance is only one element that contributes to – but does not on its own ensure – access to care. Our efforts in the health equity domain have shown clearly that language and cultural barriers, transportation, housing, food insecurity and many other factors contribute to the ability of many Michiganders to get the care they need. But at the end of the day, having insurance is a critically important first step. No one plans to get sick or injured – but when “life” happens, that coverage is nothing short of a blessing.

As always, I welcome your thoughts.

News to Know – Week of April 18

  • The MHA will host a webinar from noon to 12:30 p.m. ET April 27 to discuss compliance support for the No Surprises Act. New legislation requires verification of provider name, address, specialty, phone number and digital contact information every 90 days. MHA Endorsed Business Partner ProCredEx will review solutions to reduce the administrative burden of keeping payer partners up to date while creating a revenue stream. The webinar is complimentary for MHA members, but registration is required. To learn more about opportunities available with ProCredEx, visit the ProCredEx profile page or contact George Bosnjak at ProCredEx.
  • The MHA will host a webinar from 10 to 11 a.m. ET April 28 with ParaRev to provide coding and billing guidance related to COVID-19. Attendees will discuss ICD-10 CM official coding guidelines for COVID-19, learn about upcoming April 2022 ICD-10 codes for reporting COVID-19 vaccines and therapeutics and more. This webinar is offered free of charge, but registration is required. ParaRev is an MHA Endorsed Business Partner and a national leader in revenue cycle management with core competencies in pricing, coding, reimbursement and compliance. To learn more, visit the ParaRev profile page or contact ParaRev account executive Sandra LaPlace.
  • MHA CEO Brian Peters issued a statement April 13 on the tragic shooting of Patrick Lyoya that occurred in Grand Rapids April 4. The statement confirms Michigan hospitals’ unified commitment to address racial disparities, dismantle institutional racism and achieve health equity.

News to Know- Week of Jan. 17

  • The MHA will host a free webinar from 1 to 2 p.m. EST Jan. 25 to provide an update on price transparency and the No Surprises Act, including what is now required for compliance. MHA Endorsed Business Partner PARA will review the 15 data elements needed for good faith estimates, the mandatory disclosure notice and more. The webinar is free of charge for MHA members, but registration is required. To learn more about opportunities available with PARA, visit its profile page or connect with PARA account executive Sandra LaPlace.
  • MHA offices will be closed and no formal meetings will be scheduled Jan. 17 in honor of Martin Luther King Jr. Day.

CMS Offers Open Door Forum on No Surprises Act Dec. 8

The Centers for Medicaid & Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight will host a special Open Door Forum via conference call at 2 p.m. Dec. 8 to review provider requirements under the federal No Surprises Act.

Beginning Jan. 1, patients will have new billing protections when receiving emergency care, nonemergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. The new rules will limit out-of-pocket costs for patients and require continued coverage of emergency services without prior authorization regardless of whether a provider or facility is in network.

Slides for the call are available online in advance.  Participants can join the forum by dialing (888) 455-1397 and entering the Conference ID #8604468. The CMS will provide a transcript and audio recording at following the event. Members with questions may contact Vickie Kunz at the MHA.

Implementation Delayed on Portions of No Surprises Act

The federal departments of Health and Human Services (HHS), Labor and Treasury recently issued a frequently asked questions (FAQs) document regarding requirements for providers and health plans under the No Surprises Act and the Transparency in Coverage final rule.

Under the No Surprises Act, providers and facilities are required to prepare a “good faith estimate” of expected charges for the services the patient has scheduled. This includes expected charges for other providers and facilities used in the services. The notice is provided to the health plan or other source of coverage and will be required beginning Jan. 1, 2022.

The FAQ document says the HHS will not complete the necessary rulemaking to implement this provision of the No Surprises Act by Jan. 1 and will delay enforcement. However, the HHS does intend to do rulemaking to implement the requirement to provide an estimate of charges to patients who are not enrolled in health coverage or who will not be making a claim for services (i.e., paying out of pocket.)

The delay in enforcing the good faith estimate will also delay enforcement of the requirement that health plans and other sources of health benefits provide an “Advanced Explanation of Benefits” after they receive the estimate from the provider. The FAQs do not indicate when rulemaking will take place or estimate when enforcement will begin. For more information about these requirements and enforcement delays, contact Laura Appel at the MHA.

Regulations Released to Implement No Surprises Act

Several federal agencies, including the Office of Personnel Management and the departments of Health and Human Services (HHS), Labor and Treasury, recently released “Part 1” of the regulations to implement the No Surprises Act via an interim final rule with comment period. The rule would implement many of the law’s requirements for group health plans, health insurance issuers, carriers under the Federal Employees Health Benefits program, healthcare providers and facilities, and air ambulance service providers. Most of the provisions would take effect Jan. 1, 2022, and would:

  • Prohibit out-of-network providers from billing patients more than their in-network cost-sharing amount for emergency services and when scheduled care is provided for many nonemergent services at an in-network facility.
  • Establish a formula to calculate the “qualifying payment amount” (QPA) for use in calculating patient cost-sharing unless billed charges are less than the QPA.
  • Permit patients to waive balance billing protections if the out-of-network provider gives notice and obtains the patient’s consent using a standard notice that will be issued by the HHS.
  • Implement a process through which the departments can receive complaints about potential violations for all consumer protection and balance billing requirements with a single process applied to health plans, providers, facilities and air ambulance providers.
  • Clarify the interaction between state and federal laws and address scenarios to help identify when state versus federal law would apply, such as when the health plan license and the provider are in different states.
  • Fail to address all provisions in the No Surprises Act, such as the independent dispute resolution process. Additional regulations would be issued on those provisions.

The rule does not apply to individuals with coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care or TRICARE, since these programs already prohibit balance billing. The federal regulations also would establish requirements regarding initial payment or denial by health plans to providers, with health plans having 30 calendar days to make a payment or issue a denial notice after receiving a “clean claim.”

The MHA encourages American Hospital Association (AHA) members to register and participate in two upcoming webinars hosted by the AHA. A session to discuss the regulations will be held from 1 to 2 p.m. EDT July 21. A second webinar to discuss the association’s proposed input to the federal government will be held from 4 to 5 p.m. EDT Aug. 3.

The MHA also encourages members to review the proposed rule and contact Vickie Kunz at the MHA regarding any concerns by Aug. 27 and to submit comments on the interim final rule by Sept. 7.