A bipartisan group of lawmakers want to extend the provider relief spending deadline for certain providers until at least the end of 2021, introducing legislation in both houses about a month after HHS stopped short of the complete extension for which providers, lawmakers and hospitals had asked. While the American Hospital Association and Medical Group Management Association support the bill, the measure would only affect providers who received relief in the initial distributions.
After weeks of pressure, HHS announced on June 11 it would tie spending deadlines to when providers received their relief instead of allow for a blanket extension until the end of 2021 like some providers advocated for. The department created four relief payments periods that give providers one year to spend their funds.
Those who received more than $10,000 in relief between April 10, 2020 to June 30, 2020 are in the process of reporting to HHS how they used that funding. They have until Sept. 30 to submit all their financial information, and recipients have 30 days beyond that to return any unused provider relief.
If passed, the bicameral bill would extend the spending deadline for this first group of recipients through Dec. 31 or the end of the public health emergency, whichever is later. Reps. Cindy Axne (D-IA) and Mariannette Miller-Meeks (R-IA) said in a joint statement Thursday (July 29) an extension is necessary because some providers postponed spending their relief due to HHSâ inconsistent, confusing guidance.
Sens. Michael Bennet (D-CO) and Kevin Cramer (R-ND) introduced the same bill in the senate.
Claire Ernst, MGMA government affairs director, said many of her organization’s members are subject to first spending deadline and an extension would give them the flexibility to address rising COVID-19 cases and use the funds to pay for new protection requirements laid out in the Occupational Safety and Health Administration emergency temporary standards.
She added MGMAâs goal is for lawmakers to pass the bill before the first reporting period is over in about two months so providers donât have to report again or, if applicable, try to get returned, unused funds back from HHS.
As the bills only apply to the first provider relief reporting group, itâs not yet clear how it might affect other spending deadlines. The next provider relief spending deadline is Dec. 31 for providers who received relief anytime from July 1, 2020 to Dec. 31, 2020.
Rep. Robin Kelly (D-IL) reintroduced a bill Wednesday (July 28) that would direct HHS to study telehealthâs impact on Medicare and Medicaid during the COVID-19 public health emergency and eventually submit a report to Congress. One telehealth advocate says this bill would be a positive step forward — so long as itâs paired with an extension of telehealth flexibilities.
The bill, originally introduced in June 2019, requires HHS to write an interim report no later than one year after the end of the COVID-19 public health emergency on any changes to telehealth services made under Medicare Part A and B, as well as Medicaid. The report would be submitted to the House Energy & Commerce and Ways & Means Committees, as well as the Senate Finance Committee.
âTelehealth has the potential to help equalize healthcare access for underserved populations. However, we need data to understand utilization, cost, fraud, privacy and how to serve those left behind by the digital divide. Crucial time is ticking away, and to capitalize on the benefits of telehealth technology, we must act now,â Kelly, chair of the Congressional Black Caucus Health Braintrust, said in a statement.
The report would have to include a summary of how all health care services under Part A and B were used during the public health emergency, including the number of telehealth visits broken down by the number of audio-visual visits versus audio-only, and those delivered at a Federally Qualified Health Center, Rural Health Clinic or Community Health Center. A summary of in-person outpatient visits, inpatient admissions and emergency department visits should also be included in the report, the bill says.
The report would include a description of how use patterns for these care settings have changed over the PHE compared to use trends before the PHE.
Additionally, HHS would report out an analysis of Medicare telehealth use, access and outcomes during the PHE broken down by race and ethnicity, geographic region and income level, as well as the zip codes of where providers were when delivering services.
Descriptions of telehealth spending and saving under Parts A and B, any changes in patient access to care because of telehealth and any privacy concerns related to telehealth during the PHE would also be included in the report, as would a comparison of telehealth fraud and in-person service fraud identified by HHS during the PHE.
HHS could consult with consult with patients, tribal groups, patient advocacy organizations, medical professionals, public and private payers, and other relevant stakeholders to conduct the study, the bill says. The agency should make an effort to incorporate as many racially, ethnically, geographically and professionally diverse perspectives as possible.
A Medicaid telehealth report would also have to be submitted to Congress up to a year after the end of the PHE. This report would include items such as any changes made to telehealth benefits under state plans or waivers during the PHE, a summary of how all health care services were delivered and a description of how use patterns have changed.
Stakeholders have been urging more Congressional action on telehealth, fearing a so-called telehealth cliff at the end of the PHE if flexibilities put in place during the emergency arenât continued. A group of 430 organizations sent a letter to Congressional leadership Monday (July 26) urging them to pass laws continuing the flexibilities and giving HHS more authority when it comes to telehealth.
While both Republican and Democratic lawmakers have shown support for telehealth, stakeholders are still waiting on movement, said Krista Drobac, who directs Alliance for Connected Care, a pro-telehealth coalition.
Drobac said lawmakers have expressed they donât have enough evidence on telehealth.
âThis study bill is actually perfectly appropriate to be included into an extension, because we need to have an extension, in order to give us time to publish the research,â she said. âAnd we need time to see what happens to telehealth in non-pandemic times.”
President Joe Biden has indicated he plans to extend the PHE until the end of 2021, meaning Congressional action is necessary before the end of the year to avoid a telehealth cliff. Congress is expected to be focused on the bipartisan infrastructure package and a budget reconciliation bill for the rest of the year, though. A telehealth extension could be attached to a spending bill, Drobac said.
The PHE could also be extended into mid-2022, Drobac said, meaning there could be more time for Congress to pass telehealth extensions if the 2021 comes and goes without action.
Two of the nationâs key health insurance lobbies — AHIP and the Blue Cross Blue Shield Association — strongly oppose CMSâ plans to create a new monthly enrollment period for subsidy-eligible people earning 150% or below of poverty and to extend the open enrollment period for a month. But the lobbies representing community health plans that offer Medicaid managed care and exchange products back the SEP, and while they have differing opinions on the final deadline, they also support extending open enrollment for 30 days.
The agency had proposed these and numerous other policies, including upping exchange user fees, expanding navigator responsibilities and more in a draft rule out June 28 that CMS refers to as the third installation of the 2022 Notice of Benefit and Payment Parameters rule.
AHIP, BCBSA, Association for Community Affiliated Plans (ACAP) and Alliance of Community Health Plans (ACHP) responded to the proposals in comments due July 28.
Monthly SEP
CMS proposed a new, monthly special enrollment period (SEP) that would be limited to people earning up to 150% of poverty who generally have access to no or low-cost ACA coverage due to the increased tax credits in the American Rescue Plan. CMS says the SEP will help make sure that individuals able to stay on Medicaid due to a ban on redeterminations can easily transition into an exchange plan once the public health emergency ends.
In their comments on the rule, AHIP warns the policy could destabilize the market and urges HHS to reconsider the proposal. âDespite guardrails, like metal level restrictions, we have significant concerns this would create a revolving door of enrollment, result in adverse selection, and lead to higher premiums and fewer plan options,â AHIP says.
The health insurance industry has already dealt with significant churn as enrollees switch plans to access certain providers and the SEP would exacerbate the problem, AHIP say. The lobby also says the SEP would impact premiums more than the 0.5% to 2% increases that HHS assumes in the draft rule. Allowing consumers to switch plans could also result in their deductibles resetting, and disrupt plan efforts to help patients manage care, AHIP says. The lobby also worries that some providers might try to steer patients to certain plans at the point of service.
AHIP says federal and state officials and other stakeholders should instead increase outreach to ensure people disenrolled from Medicaid know about other coverage and help then sign up through existing SEPs. The loss of minimum essential coverage (MEC) already triggers a 60-day SEP, the lobby points out. Instead of monthly enrollment, HHS could extend that window for 30 days.
The Blue Cross Blue Shield Association (BCBSA) similarly asks HHS not to finalize the proposal, and instead focus on ensuring consumers are aware of existing enrollment opportunities. BCBSA also says CMS potentially could extend the existing MEC enrollment window.
AHIP and BCBSA both say if CMS does choose to finalize the proposal, it should include several additional guardrails to prevent destabilization. BCSA says consumers should not be allowed to switch plans once enrolled, or drop coverage and reenroll, and CMS should limit the SEP to the first few months of the year. AHIP says enrollment should be limited to those who are uninsured, and consumers should be required to enroll in silver-level coverage with the most generous cost-sharing reductions. Both lobbies say the SEP should not be effective prior to Jan. 1, 2023, because that would be too late for the 2022 plan year. BCBSA and AHIP also say that if the increased premium tax credits under the American Rescue Plan are not extended or made permanent, the SEP should also expire.
AHIP-member Centene also raised concerns about the policy during its second quarter earnings call this week, saying a SEP could create adverse selection.
But ACAP and ACHP say the SEP should move forward.
ACAP says the SEP will be useful for the potentially large numbers of Medicaid beneficiaries that will be disenrolled after the public health emergency and might need additional time to sign up. ACAP believes risk of adverse selections is low since most people have $0 premiums and no incentive to drop coverage. However, CMS should closely monitor implementation, ACAP says.
ACHP also backs the SEP but asks that the administration consider potential risk pool implications.
Open enrollment
CMS proposes to keep the Nov. 1 start date for open enrollment but extend the deadline for an additional month — from Dec. 15 to Jan. 15. The extension would bring the enrollment period closer to the Nov. 1– Jan. 31 timeframe in effect during the last three years of the Obama administration. The later deadline was also meant to help people who might have been automatically reenrolled in a plan with higher premiums and currently have no chance to find another option. HHS also asked stakeholders to comment on whether a special SEP should be created for that population as an alternative to the deadline extension.
AHIP and BCBSA both say CMS should maintain the current dates. âA single enrollment deadline creates a consistent message and allows issuers, agents and brokers, and other enrollment assisters to reinforce the deadline through streamlined messaging,â AHIP writes. The lobby also worries that many consumers may wait until after Dec. 15 to enroll, which means their plan would not be effective until February, which could create gaps.
AHIP supports CMSâ alternative proposal of a SEP for people auto reenrolled into a higher cost plan.
BCBSA also says that a broad extension of the open enrollment period is not needed to solve the problem that CMS is attempting to address.
âInstead of lengthening the annual open enrollment period for all enrollees in all exchanges, we recommend, starting in 2023, allowing auto-renewed enrollees who face premium increases to change their coverage up until Jan. 31,â BCBSA writes. The lobby also urges CMS to increase targeted outreach to that population and to ensure that consumers are getting accurate information on subsidy-levels as early as possible.
But ACAP supports the open enrollment extension. In addition to issues CMS discussed in the rule, ACAP says its plan have noticed some consumers are not reenrolled because they have been in a grace period for non-payment, and these enrollees may not realize their coverage been terminated until after Dec. 15. The extra 30-day enrollment period would give these consumers a chance to find a new plan and enroll in coverage for at least 11 months of the year, ACAP says.
ACA also urges CMS to draft rules that require any non-ACA compliant health plans to have a coverage term ending Dec. 31 and to ban sales of such plans during open enrollment.
ACHP supports giving consumers another 30 days to enroll in ACA coverage, but suggests CMS consider moving the start date from Nov. 1 back to Oct. 15, and setting a Dec. 31 deadline for coverage effective Jan. 1.
âThe current proposal would push the enrollee coverage start date to Feb. 1, resulting in a consumer having just 11 months of coverage, âACHP writes.
The Jan. 1 start date would have fewer operational burdens, help with marketplace stability, and ensure Americans are offered a full 12-month coverage period, which is the basis of plan benefit actuarial design and pricing, ACHP says. — Amy Lotven (alotven@iwpnews.com)
States would be able to use Medicaid money to pay for home health workersâ health and training benefits or union dues under a proposed rule issued Friday by the Centers for Medicare & Medicaid Services.
The proposed rule, if finalized, would re-establish statesâ flexibility to allow home care workers and personal care assistants to enroll inâand use Medicaid to pay forâ”typical employee benefitsâ like health insurance or employee training. It would apply to individual health practitioners who rely on Medicaid for their livelihood, generally by taking care of some of the âmost vulnerableâ beneficiaries in their own homes, the CMS said in a statement. These workers are paid directly by the people for whom they care using Medicaid.
The proposal also is intended to resolve problems that the U.S. District Court for the Northern District of California found with a 2019 rule that barred payments to third parties on behalf of states to home health workers. Several states, led by California, sued the Department of Health and Human Services over that rule, saying it was âin service of anti-union objectives that bear no relationship to the purposeâ of the law governing Medicaid. Previously, states could opt to allow Medicaid to pay for union dues for home health workers.
The plaintiffs claimed the 2019 rule harmed individual Medicaid beneficiariesâmany of them with disabilitiesâby upending careful arrangements ârelating to the financial logistics of paying care providers.â
The district court vacated that rule and remanded it to the HHS for a rewrite. Alex Azar, then the HHS secretary, appealed to the U.S. Court of Appeals for the Ninth Circuit on Jan 15, five days before President Joe Biden took office. The court docket for that case is temporarily closed until February 2022, but any party to the suit can request that it be reopened before then.
In a footnote, the proposed rule address the question of union dues, saying âto the extent state agencies utilize this option to deduct union dues, union dues may only be deducted from Medicaid payments with the affirmative consent of the practitioner.â
A final rule setting Medicare hospital payment rates for 2022 has cleared White House review and can be published at any time by the Centers for Medicare & Medicaid Services.
The proposed rule issued in April would give acute-care hospitals an overall 2.8% increase, or another $2.5 billion, in fiscal year 2022.
Long-term care hospitals would receive an extra 1.4%, or $52 million under the proposal (RIN 0938-AU44), which published May 10 in the Federal Register.
In 2019, Medicare paid acute-care hospitals $186 billion for 8.7 million inpatient stays on behalf of roughly 5.5 million beneficiaries, according to the Medicare Payment Advisory Commission.
Long-term care hospitals have an average length of stay of more than 25 days. In 2019, Medicare paid these hospitals $3.7 billion for about 91,000 stays on behalf of 82,000 beneficiaries, the commission reported.
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President Joe Biden urged Senate Democrats to act boldly on his sweeping social and economic agenda Wednesday, as they began hashing out details of an $3.5 trillion tax and spending agreement that marks a crucial step forward for his plan.
Biden himself hasnât yet said whether he supports the proposal unveiled by Democrats on the Senate Budget Committee Tuesday night, though top aides have expressed enthusiasm.
âWeâre going to get this done,â Biden told reporters as he arrived at the Capitol.
If it holds, the budget agreement will be a victory for the president, bridging divisions among party factions over the size and scope of the package. But itâs a crucial moment for Biden, who must persuade Democratic progressives to agree to lower spending than they wanted while keeping moderates from balking at the price tag.
The budget measure would accompany a separate, $579 billion bipartisan infrastructure plan that Biden has endorsed, raising the total spending of his economic agenda beyond $4 trillion.
The draft budget proposal does not yet have the firm support of all 50 members of the Democratic caucus in the Senate, which it would need in the face of united Republican opposition. Democratic leaders also have only a thin margin in the House and are trying to head off dissent from progressives, who want even higher spending levels.
Earlier: Biden Agenda Gets Boost on Democratsâ $3.5 Trillion Proposal
A senior Democratic official said the $3.5 trillion in proposed spending would be offset by health care savings, tax hikes on companies and the wealthiest Americans, and economic growth. An expansion of Medicare would be funded by cuts to drug prices, while higher emission standards and carbon tariffs would be used to combat climate change.
At a Democratic lunch, Biden told Democrats that they have to do a better job connecting with working class voters on kitchen table issues and that both the bipartisan infrastructure plan and wider tax and spending bill can do that, according to a person familiar with the event. The president said that polls show majorities of Americans support changing the tax code to make it less favorable for the wealthy.
Senator Joe Manchin of West Virginia, a key moderate Democrat, didnât speak at the meeting but said earlier Wednesday the price tag would have to be fully offset with spending cuts, tax increases or other measures and that the tax increases should not hamper U.S. competitiveness on the global stage.
âWe are going to have to pay for all this,â Manchin told reporters at the Capitol.
Senator Mark Warner of Virginia, another moderate, said Tuesday the bill would be âfully paid for.â
Montana Senator Jon Tester, also a moderate, said he, too, was waiting to see more details before committing to support the plan. âThe issue is $3.5 trillion is a lot of money,â Tester said. âIt doesnât scare me if it is spent appropriately and over the right amount of time. We will analyze that.â
In the House, Representative Pramila Jayapal, head of the Congressional Progressive Caucus, said the groupâs support isnât guaranteed without knowing details about how their priorities are dealt with. House Speaker Nancy Pelosi praised the Senate Budget Committee agreement as âa victory for the American people.â
The White House must also keep Senate Republicans on board with the separate, bipartisan infrastructure deal. Some Republicans have expressed concern that by supporting the smaller bill, they are paving the way for Democrats to pass their sweeping agenda through Congress. Theyâve urged the White House to disconnect the two measures.
Under special rules known as budget reconciliation, only a simple majority is needed to pass the $3.5 trillion Democratic economic plan through the Senate. But with the upper chamber split 50-50, Democrats canât afford any defections because Republicans are expected to unanimously oppose the budget resolution.
âThere are bumps along the way,â Senate Majority Leader Chuck Schumer said Wednesday. âBut we are going to get this done.â
Senate Minority Leader Mitch McConnell, a Kentucky Republican, raised the specter of rising inflation in castigating the Democratic plan, calling it âwildly out of proportion to what the country needs right now.â
Read more: U.S. Consumer Prices Jump Most Since 2008, Topping All Estimates
The agreement nonetheless marks an achievement for Democratic leaders. Budget Committee Democrats had been divided over the cost of the plan and which policies to include. Chairman Bernie Sanders initially pushed for a $6 trillion measure that added an expansion of Medicare, the health program for the elderly and disabled, an immigration overhaul and more generous childcare benefits, along with other items, to Bidenâs initial proposal.
Senator Richard Blumenthal, a Connecticut Democrat, said Bidenâs message to the caucus was âvery, very friendly.â
âIt was do it big, do it bold. This is an historic opportunity,â Blumenthal said. âHe emphasized the importance of the moment.â
The Budget Committee agreement includes Medicare expansion and provisions on immigration and prescription drugs, marking a significant win for Sanders.
âItâs a work in progress, but all I can tell you is that every issue that I have been talking about is in this proposal. Everything,â he said Wednesday.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has awarded 100 grants to increase access to facilities throughout the nation that provide community-based support for Americans in need of substance use disorder and mental health treatment services. Totaling $250 million, including $77 million from the American Rescue Plan (ARP), the grants support the Biden-Harris Administration’s priority of addressing the behavioral health needs of Americansâparticularly those impacted by the COVID-19 pandemic.
The Certified Community Behavioral Health Clinics (CCBHC) expansion grant program increases access to and improves the quality of community mental and substance use disorder treatment services. CCBHCs provide person- and family-centered integrated services, including 24/7 crisis intervention services for individuals with serious mental illness or substance use disorders, including opioid use disorders; children and adolescents with serious emotional disturbances; and individuals with co-occurring mental and substance use disorders.
The $77 million added by the American Rescue Plan helps expand the CCBHC program in both breadth and depth. These funds â part of the $420 million appropriated for CCBHC expansion grants in the American Rescue Plan â will help the program establish services in new facilities and make services more robust at existing facilities at a time when the COVID-19 pandemic has increased behavioral health needs throughout the country.
“As we continue to confront the impact of the pandemic, increased support for mental and substance use treatment can be a critical lifeline to communities across the country,” said Health and Human Services (HHS) Secretary Xavier Becerra. “These new resources reflect our commitment to expanding access to quality care for everyone in need.”
“The ability to provide coordinated and centralized careâincluding crisis intervention along with substance use disorder and mental health servicesâwas crucial before the COVID-19 pandemic. The urgency to connect Americans to such easy-to-access treatment and services has increased exponentially since,” said Miriam E. Delphin-Rittmon, Ph.D., HHS Assistant Secretary for Mental Health and Substance Use and the leader of SAMHSA. “The addition of the American Rescue Plan and COVID-related funding will contribute significantly to increasing opportunities for recovery from mental health and substance use problems by improving access to certified community behavioral health clinics, as well the level of care they deliver.”
The Certified Community Behavioral Health Clinics provide community-based mental and substance use disorder services, advance integration of behavioral health with physical health care, assimilate and utilize evidence-based practices on a more consistent basis, and promote improved access to high quality care. They coordinate and organize care activities among different services and providers, and across various facilities, a key aspect to providing improved treatment services in the community.
The 100 grants comprise $115 million in COVID relief funds, $77 million in American Rescue Plan funds and $58 million in annual appropriations. View recipients of the CCBHC Expansion Grants, and read more about the grant program.
Hospital and doctorsâ groups successfully lobbied to save Covid relief money earmarked for their members, while pharmaceutical companies are expected to lose billions of dollars as part of a bipartisan infrastructure deal struck Wednesday.
The $550 billion infrastructure package negotiated by a bipartisan group of senators would be paid in part by delaying a Trump-era regulation to end some pharmaceutical rebates and refunds from drugmakers for some kinds of physician-administered single-use medicines.
Senators Reach Infrastructure Deal; Schumer Preps First Vote
Not included in the deal: a clawback of $43.7 billion in unspent Covid relief funds marked for health-care providers, which lawmakers had considered taking back. Sen. Ron Wyden (D-Ore.) confirmed the relief funds were untouched.
Leaning on cost offsets that affect the revenue of drugmakers, rather than those of health-care providers, highlights which sector has a bigger constituency in Congress.
âCases are going up,â Wyden said of Covid-19 prevalence in the U.S. âI want to make sure this doesnât impact our nursing homes and hospitals that are getting hit.â
He added that he doesnât support how the Trump administration designed the rebate rule, and plans to put together a drug pricing bill later this year.
The Trump rule aims to end Medicare rebates to pharmaceutical middlemen and make drugmakers pass any discounts to consumers. That could balloon Medicare drug benefit premiums, which are subsidized by the government.
Hospital groups such as the American Hospital Association lobbied against rescinding the relief funds.
The infrastructure package includes a provision that seeks refunds from drugmakers for some kinds of physician-administered single-use medicines, a move that lawmakers estimate would save the government $3 billion, according to a summary of the provision shared with Bloomberg Government.
The Pharmaceutical Research and Manufacturers of America, the drugmakersâ lobby, supported the rebate rule from the Trump administration and sought to keep it in place.
Sen. Bill Cassidy (R-La.) said he supported the rebate rule but Democrats signaled they were planning to block it, so it became a pay-for.
âI actually agree with the policy but it was 186 billion in costs of the Treasury,â he said, referring to the cost of fully implementing the rule over a decade.
Infrastructure Gang Targets Pharma to Pay for Roads, Bridges
One area providers didnât win: The package will delay the Medicare sequester by less than a year, saving the government almost $9 billion.
The sequester, or planned cuts to hospital and doctor reimbursements, is set to run from fiscal 2022 to 2030. These cuts were originally slated to run from fiscal 2013 to 2021 but have repeatedly been delayed and extended.
A group of lawmakers and the White House struck a $550 billion deal to revitalize the nationâs transportation and utility infrastructure after weeks of negotiations, meeting a key goal of President Joe Biden: a large, bipartisan bill.
The Senate plans to vote to begin consideration of the legislation, which has yet to be completed, as soon as Wednesday night. The release of the bill text, as well as additional debate and votes could occur in the coming days.
Hereâs whatâs in the deal:
The deal calls for spending $110 billion on roads, bridges and other major projects. This includes $40 billion for bridge repairs and replacement, as well as $17.5 billion for major projects. It also would reauthorize the surface transportation program for the next five years.
The plan includes $39 billion to modernize transit and improve accessibility. In addition, the deal would continue existing transit programs for five years as part of the surface transportation reauthorization.
The deal would allocate $66 billion to Amtrak for maintenance, to upgrade tracks in the Northeast Corridor and bring rail service — including high-speed rail — to other areas of the country.
The deal includes $73 billion for power grid upgrades, including building thousands of miles of new transmission lines for renewable energy and research for new technologies like nuclear reactors and carbon capture.
The bill would spend $7.5 billion to build a nationwide network of charging stations for electric vehicles to help accelerate the adoption of non-fossil fuel cars.
The plan includes $5 billion for new school buses, although the program would allow half of that to go toward buses that run on natural gas or diesel. The plan also includes $2.5 billion for ferries.
The plan would provide $25 billion for airport repairs and efforts to reduce congestion and emissions. That includes encouraging the use of electric and other low-carbon technologies. It would also invest $17 billion in port infrastructure.
The deal includes $50 billion to help communities ward off cyber attacks and the effects of climate change. The funds include money to protect against droughts and floods.
The package spends $55 billion to improve drinking water, including dedicated funding to replace lead pipes and dangerous chemicals.
The plan would invest $65 billion in high-speed internet to ensure that every household can access reliable broadband service.
The package has $21 billion dedicated for environmental remediation to address past pollution that harms public health.
The plan also includes $1 billion to reconnect communities that have been divided by past infrastructure projects, such as highways splicing through established areas.
The plan would spend $11 billion on transportation safety, including programs to reduce crashes and fatalities, especially for cyclists and pedestrians.
Here are some of the major ways that lawmakers have agreed to offset the cost of the spending:
A group of lawmakers and the White House struck a $550 billion deal to revitalize the nationâs transportation and utility infrastructure after weeks of negotiations, meeting a key goal of President Joe Biden: a large, bipartisan bill.
Telemedicine didnât just provide a pandemic lifeline for patients and their doctors. Itâs linking rural hospitals with offsite clinicians who consult on patient care and back up on-site doctors and nurses as Covidâs latest surge fills beds once again.
With the highly transmissible Delta variant of Covid-19 now overtaking areas with low vaccination rates, demand for tele-ICU and tele-ER services is on the rise as hospital administrators try to shorten the length of stays and avoid transferring medically frail patients over long distances to higher levels of care.
Matthew Lyon, service chief of virtual care operations at Augusta University Health, in Georgia, said most hospitals his facility collaborates with remotely monitor one or two Covid patients. A month ago, it was one in every 10 or 12 hospitals.
Kelly Rhone, medical director of outreach and innovation at Avera eCARE, a leading tele-ICU provider in Sioux Falls, S.D., has begun seeing sicker younger patients at facilities her company connects with in the upper Midwest and Great Plains states.
âWe don’t know what the future holds with Delta or any other variants that are coming, but we know that this system works to help with that,â Rhone said.
The fiber opticâconnected setup keeps cameras trained on patients. Nurses or board-certified doctors in a command center watch vital signs like heart rates or blood oxygen levels on monitors. A data point change prompts a real-time response, with the virtual care team able to jump in and assist with ordering tests, updating case notes or, in serious cases, putting patients on ventilators.
Providers say some patients gave the virtual experience high marks, while othersâ experience was mixed. Marshall Lee, medical director of the virtual ICU at Oregon Health & Science University, said a number of those hospitalized “wonder what’s going on with the camera,” but have appreciated the attention when hospitalsâ in-house staffs are stretched thin.
Hospitals benefit from keeping more patients in their communities and getting a more predictable revenue stream during a crisis thatâs seen many elective procedures and routine care curtailed. Providers like Avera also charge by the cameras in operation, allowing facilities to scale up care without lots of abrupt staffing changes.
The consultations also reduce the need to shuttle patients to hospitals in big population centers, some of which are experiencing their own Covid crises. A report from Augusta University Health found its tele-ER program cut patient transfers from rural hospitals in Georgia by 81 percent last year.
With almost 30 million Americans living more than 60 minutes from a trauma center, demand for âteletraumaâ could outlast the Delta variant and future Covid surges. Hospitals with limited critical care like KershawHealth Medical Center in Camden, S.C., use hookups with offsite doctors for every patient in the ICU, and had leaned on the tech before the pandemic. The arrangement proved invaluable during the health crisis, when patients were far sicker than normal, said Tallulah Holmstrom, KershawHealthâs chief medical officer.
Augusta University Health sees future growth in areas like pediatric care and in collaborations with skilled nursing and rehabilitation facilities once patients are discharged. âWe think it really helps decrease this rural-urban disparity,â Lyon said.
A diverse group of 18 health care stakeholders including beneficiary advocates, insurers and businesses are pushing a legislative agenda that includes expanding and strengthening coverage in Medicaid/CHIP and the exchanges.
Many of the policies they support are expected to be in the budget reconciliation package being put together by the Democrats, but others could be included in subsequent vehicles.
The stakeholders offer dozens of ideas in their seven-page memo but point to four policy priorities: strengthen funding and expand eligibility for Medicaid/CHIP; improve the affordability of plans sold on the marketplaces; qualify all legal immigrants into public health programs without a waiting period; and enroll people who are eligible but not enrolled in low-cost coverage.
The policies are backed by Families USA, Association for Community Affiliated Plans (ACAP), Small Business Majority, National Immigration Law Center (NILC), AHIP, American Academy of Pediatrics, American College of Physicians, Blue Cross Blue Shield Association, Catholic Health Association of the United States, Federation of American Hospitals, NAACP, National Birth Equity Collaborative, National Council of Urban Indian Health, National Health Council, National Partnership for Women & Families, Third Way, UnidosUS and Young Invincibles.
âThe deadliest pandemic in more than a century and sharpest economic downturn since the Great Depression have made it crystal clear that affordable, high-quality coverage is critical to the entire nationâs well-being, not just individual families,â Frederick Isasi, executive director of Families USA, said when unveiling the policy agenda on July 12.
âIf our elected leaders donât act, we will have wasted the most devastating lesson of our lifetimes. Passing these commonsense proposals, which enjoy broad support from across the political spectrum, would be a strong statement that America is going to come back stronger than ever,â he said.
âThese proposals provide concrete actions lawmakers can take to address long-standing gaps in coverage brought into sharp relief by the COVID-19 pandemic,â adds Margaret A. Murray, CEO of ACAP.
The lobby especially supports policies that, like continuous eligibility in Medicaid, would prevent consumers from churning between health programs, which threatens health care outcomes and creates bureaucratic hurdles.
âAll of us, no matter how much money we have, what we look like or where we were born, should have access to quality and affordable health care, says Avideh Moussavian, director of federal advocacy at the NILC. âBut for too long, health care programs that keep communities healthy have excluded immigrants through eligibility restrictions, outreach failures, and a lack of affordability.â
David Chase, vice president of outreach for the Small Business Majority, says that millions of small businesses, especially those in underserved communities, were disproportionately impacted by the pandemic and âhelplessly as revenues needed to pay health premiums were wiped out overnight.”
âCongress now has an opportunity and obligation to enact substantive policies that will make high-quality health care coverage affordable for small businesses as they try to rebuild from the devastation of the pandemic. The many and diverse organizations that collaborated on this project is evidence that common-sense solutions can be reached across a broad spectrum of missions,â he said
âWe call on lawmakers to review the menu of policy options outlined and consider including some or all in their next legislative package,â Chase added.
Democrats have already said that they plan to include several of the priorities in the reconciliation package, including closing the Medicaid gap and permanently extending the increased tax credits and help for higher-income families in the American Rescue Plan.
Lawmakers also want to expand funding for home- and community-based services, and add dental, vision and hearing benefits to Medicare.
Those health care policies could make up close to a third of the $3.5 trillion that the Senate Budget Committee Democrats tentatively agreed upon for the reconciliation package, but that top-line has not yet been approved by the full caucus and is expected to come down, which means the heath policies may need to be trimmed.
Isasi says the haircut phase is because the pay-for are still unsettled, and much will depend on the whether Congress can pass meaningful drug pricing reforms. The drug-pricing pay-for could be as much as $450 billion under the House drug pricing bill or less than $100 billion depending on what Senate Finance Committee Chair Ron Wyden (D-OR) includes in the alternative bill he is drafting.
Thereâs a lot of excitement on the new oral benefit, and a well-identified need, Isasi says. But thereâs no way to answer whether the new benefit — which costs an estimated $230 billion — can make the final package until they do the math. Inside Health Policyrecently reported that the administration could administratively expand medically necessary dental coverage, which could lower the cost of what Congress might add on dental benefits. Isasi expects to see an announcement from CMS as early as August.
Families strongly supports all of the health policies slated for the package, and Isasi says the current experience with the Delta variant of COVID-19 underscores the need to act quickly.
Policy proposals:
Medicaid and CHIP. For Medicaid, the group says the federal medical assistance percentage (FMAP) should be given the flexibility to automatically increase during downturns and include maintenance of effort policies. This would make Medicaid a powerful took to combat recession and while protecting families and state budgets, the stakeholders say.
The group also urges Congress to make CHIP funding permanent; lift funding caps and establish FMAPs for Puerto Rico and other territories that are no less generous than what states receive and provide 100% FMAP for Urban Indian Health Programs. Congress should enact policies that prevent coverage disruptions in Medicaid and CHIP by providing — and sufficiently funding – five-year continuous enrollment for young children, 12-month eligibility for children and adults, 12-month continuous eligibility for postpartum care to address high maternal mortally rates and higher FMAP.
They also call for automatically enrolling newborns in Medicaid if thereâs no other proof of coverage. âThis includes automatic enrollment in the motherâs Medicaid plan unless the parent or parents choose a different plan for their child,â the proposal says. Also, Medicaid should cover the justice-involved populations 30-days prior to release to prevent any disruptions in care.
The stakeholders also support policies to close the Medicaid gap, saying Congress should provide Medicaid-level coverage for the 2 million uninsured people that live below poverty in states that have refused to expand their Medicaid programs. This policy should be coupled with significant incentives for states to retain or further expand the program, according to the proposal.
Equity-focused Medicaid improvements like language access, telehealth services, and perinatal care should also be on the agenda. Medicaid should also be required to cover adult dental services – including for those dually eligible for Medicare.
Regarding lawfully present immigrants, the groups call for removing any statuary restrictions – including waiting periods – that block that population from enrolling in public health programs.
A recent Health Affairs article found that non-citizen children face more harm than their siblings that are citizens, including delays in needed care largely due to the lack of insurance. The authors suggest the United States âreexamine policies that exclude noncitizen children from public health insurance programs,â according to an abstract.
ACA reforms. To improve affordability of marketplace plans, the stakeholders call for the permanently extending the increased tax credits in the American Rescue Plan. They also say the APTC structure should be tweaked to offer more support for younger adults, which the Blue Cross Blue Shield Association (BCBSA) has been pushing for years. The policy should not result in increased premiums for older adults, the proposal says.
The stakeholders also want the ACAâs cost-sharing reductions funded and extended to people earning up to 400% FPL, and say the premium tax credits should be linked to the gold level with an 80% actuarial value rather than silver-level plan with 70% AV.
Both policies, as well as permanently expanding the ARP tax credits, are included in legislation sponsored by Sen. Jean Shaheen (D-NH), the Improving Health Care Affordability Act (S. 499). Shaheen’s office said recently that driving down deductibles and cost-sharing is critical to ensuring consumers can use their coverage without facing high out-of- pocket costs.
âThese policies enjoy support from across the ideological spectrum within the Democratic caucus and need to be a part of the discussion when the Senate considers legislation to bring down health care costs,â Shaheenâs office said in a recent email.
Stakeholders also call for a fix of the âfamily glitch,â which currently blocks about 5 million dependents from accessing the ACAâs premium tax credits if a worker is offered affordable self-only coverage even if the offer for family coverage is unaffordable. The fix should be structured so that is does not expose employers to additional liability, the groups say.
Congress has yet to include a fix to the glitch in any recent proposals, but sources say the administration is working on a regulatory solution that would allow family members to get subsidies even if the employee is enrolled in employer coverage.
Tax credits should be available for student health plans that fully comply with the ACA, which would help low- and moderate-income student access affordable coverage, the stakeholders say.
Enrollment and eligibility reforms across programs. Finally, the stakeholders call for mechanisms that would help ensure all eligible beneficiaries are enrolled in coverage. The groups say Congress should make enrollment as automatic as possible by allowing consumers to consent on their tax forms to sharing their information with the relevant insurance exchange to determine coverage eligibility. Eligible consumers could also be enrolled into a $0 premium coverage plan, CHIP or Medicaid if they donât choose a different plan or opt out.
They also suggest basing eligibility for public programs on prior year tax forms, creating pathways for people on unemployment to access insurance assistance programs and making permanent Express Lane Eligibility, which streamlines enrollment in other benefit programs, like SNAP, with Medicaid.
More than 400 organizations, mostly health care providers and technology companies, pushed for COVID-19 telehealth flexibilities to be made permanent in a letter sent to congressional leadership Monday (July 26).
Telehealth has exploded since the onset of the COVID-19 public health emergency, thanks in part to temporary flexibilities from CMS that allow providers to be reimbursed for telehealth at parity with in-person services and make it easier for telehealth to be used by both providers and beneficiaries.
But the letter points out that most of these flexibilities are limited to the duration of the PHE, and Congress has not yet acted to protect access to telehealth into the future.
The organizations argue that telehealth is not a âCOVID-19 novelty,â and say that if Congress doesnât act, losing telehealth options could have a chilling effect on health care availability throughout the country.
âIt is far past time to update our telehealth laws. These are arbitrary restrictions that should be removed,â Jen Covich Bordenick, CEO of eHealth Initiative, said in a statement following the letterâs release. âThe pandemic highlighted just how outdated our current law is. Congress needs to take immediate action to ensure millions of patients do not lose access to care delivered via telehealth.â
The letter comes after a bipartisan group of lawmakers sent a letter to HHS Secretary Xavier Becerra urging him to work with Congress to permanently expand telehealth post-PHE. Becerra has said he does not plan to go backwards on telehealth coverage but could use assistance from Congress.
CMS also proposed earlier this month to extend limited telehealth services for mental health after the PHE. This would include allowing audio-only telehealth for mental health services but only when the provider has the capacity for two-way, audio-visual communications, and requiring an in-person visit before tele-mental health services can begin and at least once every six months after.
The groups that signed onto the letter say the proposed requirement for an initial in-person visit isnât based in clinical support and could further health inequities. They ask Congress to step in.
The groups want geographic and originating site restrictions for telehealth removed as well. Many states have already gotten rid of these restrictions on their own books.
âRemoving geographic and originating site restrictions only to replace them with in-person restrictions is short-sighted and will create additional barriers to care,â the letter says.
The letter also calls on Congress to give HHS more authority to determine who can provide services through telehealth, and to add or remove telehealth-eligible services through regulation. Congress should allow HHS to reimburse for audio-only telehealth and other modalities, too, the letter says.
Additionally, the groups want Congress to make sure Federally Qualified Health Centers, Critical Access Hospitals, and Rural Health Clinics can still provide telehealth services post-PHE. This includes offering appropriate reimbursement to the provider types.
Given restrictions written into the Social Security Act, congressional action is needed to give HHS authority to extend these temporary policies, the letter says.
Claire Ernst, director of government affairs for the Medical Group Management Association, which signed onto the letter, said MGMAâs members are nervous about facing a so-called telehealth cliff as the end of the PHE looms. So far, the emergency designation and the flexibilities it allows are likely to be extended through 2021, but that means Congress should act soon, Ernst said.
â[W]e would definitely want to see legislation move on this before the year is over,â Ernst said in an email.
A coalition of hospitals sued HHS Secretary Xavier Becerra in federal court to force him to recalculate their Medicare reimbursements for doctor training programs.
The plaintiffsâincluding New Yorkâs Hospital for Special Surgery and Yale New Haven Hospitalâsay in a complaint filed in the U.S. District Court for the District of Columbia that they have been underpaid for the past several years due to the secretaryâs application of an arbitrary and capricious regulation.
The regulation effectively changed the weights assigned to full-time equivalent residents and fellows by the Medicare Act, the hospitals say. As a result, they have been prevented from claiming direct graduate medical education reimbursement in the amount authorized by the Medicare Act, they say.
Under the Medicare Act, hospitals are reimbursed for costs associated with training residents and fellows, such as stipends, salaries, and administrative costs. The amount is calculated in part by multiplying a per resident amount by the weighted average of a hospitalâs full-time equivalent residents.
By law, residents in their first through fifth years of residency receive a weighted average of 1.0, while residents in their sixth year and beyond receive a weighted average of .5. A hospitalâs reimbursements are capped at the number of residents and fellows it had in 1996.
The 1997 regulation calls for calculating the weighted average using a weighted FTE cap instead of an unweighted FTE cap, the hospitals say. This results in a reduction of more than .5 for residents beyond their initial residency period, which in turn prevents the hospital from claiming direct graduate medical education reimbursements up to the full amount authorized, they say in Mondayâs complaint.
Causes of Action: Medicare Act, Administrative Procedure Act.
Relief: Declare regulation invalid, order secretary to recalculate hospitalsâ payments, award interest, costs and attorneysâ fees.
Response: HHS doesnât comment on pending litigation as a matter of policy.
Attorneys: Powers Pyles Sutter & Verville PC represents the hospitals.
Hundreds of health and technology groups urge Congress to extend telehealth flexibility for Medicare beneficiaries past the end of the Covid-19 pandemic.
Last yearâs CARES Act let the Centers for Medicare & Medicaid Services temporarily waive certain restrictions on how providers can deliver remote care.
A Biden administration proposed rule (RIN 0938âAU42) would extend temporary Medicare coverage of some telehealth services through Dec. 31, 2023, but the 430 groups said in a letter to congressional leaders that they donât think the proposal goes far enough. They want telehealth to become a permanent fixture of the health-care system.
The groups that signed the letter included the American Medical Association, the American Board of Telehealth, the Alliance for Connected Care, the Federation of American Hospitals, Amazon, Google, and Zoom Videoconferencing.
âWithout action from Congress, Medicare beneficiaries will abruptly lose access to nearly all recently expanded coverage of telehealth,â according to the groupsâ letter.
âThis would have a chilling effect on access to care across the entire U.S. health system, including on patients that have established relationships with providers virtually, with potentially dire consequences for their health,â the letter stated.
Telehealth use has increased dramatically during the pandemic because many patients have been unwilling or unable to see doctors in person. Telehealth represented 0.22% of private health plan medical claims in December 2019, booming to 6.51% in December 2020, according to data from FAIR Health.
Virtual visits have been especially helpful to mental health providers who are having a hard time meeting the demand of an ever-growing population of patients seeking care.
Beneficiaries like telehealth too, with 75% of Americans showing âa strong interest in using telehealth moving forward,â according to a telehealth study from the COVID-19 Healthcare Coalition.
The CMS canât permanently expand telehealth without changes to the Social Security Act, which limits the telehealth services Medicare can and canât pay for. Before Covid-19, Medicare would only cover visits for beneficiaries in certain rural locations that originated in qualifying sites.
Given these restrictions, âCongress must act to ensure that the Secretary has the tools to transition following the end of the public health emergency and ensure telehealth is regulated the same as in-person services,â the letter said, referring to Department of Health and Human Services Secretary Xavier Becerra.
The groups asked Congress to remove the geographic restrictions on patients and providers. The pandemic has demonstrated the importance of telehealth services âin rural and urban areas alike,â they said.
The groups want Congress to ensure flexibility in which services are eligible for telehealth and how they are delivered. Audio-only services should be permitted for reimbursement by the CMS âwhen clinically appropriate,â they said.
They want to remove a new restriction that would require mental health patients to have an in-person visit every six months. âNot only is there no clinical evidence to support these requirements, but they also exacerbate clinician shortages and worsen health inequities,â they said.
Several telehealth bills are moving through Congress, which range from directing the HHS to extend Covid-19 flexibility (S. 368) to a widely supported bill that would amend the Social Security Act to expand telehealth access (S. 1512). Lawmakers are also pushing for legislation that addresses the in-person requirement for mental health services (S. 2061).
While these bills would improve access, the Alliance for Connected Care signed the letter because âwe wanted to keep the pressure on,â Executive Director Krista Drobac said. âWe need Congress to take action.â
âCongress not only has the opportunity to bring the U.S. health care system into the 21st century, but the responsibility to ensure that the billions in taxpayer funded COVID investments made during the pandemic are not simply wasted but used to accelerate the transformation of care delivery, ensuring access to high quality virtual care for all Americans,â the groups said in their letter.
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