TGIF

As you know, the current continuing resolution funding the federal government expires on January 15.  The Associated Press via Federal News Radio reports that 

House Appropriations Committee Chairman Harold Rogers says bipartisan negotiations on the broader spending bill will carry into the weekend in hopes that an agreement can be sealed by Sunday or Monday. The secretive talks have yielded agreement on at least eight of the omnibus bill’s 12 titles. But issues like funding implementation of the new health care law remain unresolved. 

The House leadership is proposing a three day extension of the continuing resolution in order to allow for the conclusion of negotiations and the application of regular order to the resulting omnibus appropriations bill.

As you also know, we are on a path that leads to Super Bowl XLVIII next month. Yesterday, the Affordable Care Act regulators came out with ACA Frequently Asked Questions XVIII.  What is the likelihood that the ACA regulators will reach FAQ L at the same time the NFL play Super Bowl L in 2016?

Enough musing though, the FAQs announce a new preventive care mandate that will apply to the FEHBP for 2015. The U.S. Preventive Services Task Force B level recommendation provides that “For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.” The ACA regulators make it clear that health plans must cover the prescription drugs not just the physician counselling with no member cost sharing in network subject to reasonable medical management practices. (The rule applies only to non-grandfathered plans which at this point are few and far between — the FEHBlog places this qualification in parentheses because OPM sensibly disregards this fine point for FEHBP purposes.)

The FAQs also allow plans to break up the statutory in-network out of pocket maximum applicable to FEHB and other group health plans (in 2014 $6,350 for self-only coverage and $12,700 for coverage other than self-only coverage) among different benefit categories as long as medical/surgical and mental health / substance abuse conditions fall under the same category. For 2014 only, plans can impose separate $6,350 / $12,700 limits on separately administered benefits like prescription drugs. But that administrative waiver is gone for 2015.

The FAQ is 10 pages long and full of good stuff.

Finally, for thirty years, CMS has exempted the State of Maryland from Medicare’s prospective payment system. Maryland has used its own system to regulate hospital prices, and Kaiser Health News reports that CMS has blessed a “radical” change to Maryland’s system.    

After months of negotiations with state and the federal officials, the hospitals also agreed that their revenue from all sources — private insurance, government and employers — will rise no faster than growth in the overall state economy.
Maryland regulators with the power to cap spending will enforce the agreement, which analysts say could serve as a model for other states and eventually the nation. Enforcement muscle gives Maryland’s deal a better chance to succeed than a similar measure passed last year in Massachusetts, analysts said.
“Maryland is actually doing a leapfrog over Massachusetts,” said John McDonough, a Harvard University professor and former state legislator who helped design Massachusetts’ 2006 insurance-coverage expansion. “It really establishes a new frontier in terms of controlling growth.”  * * * Specifically, [starting in 2014] statewide hospital revenue for inpatient as well as outpatient care will rise no more than 3.58 percent annually — the state’s rate of per-capita economic growth since 2002.

Time will tell. Price controls do not have a great history of success. The article concludes by musing that Maryland hospitals took this deal because insurers outside Maryland are “starting to pit hospitals against each other, presenting a risk of a fierce price war like airlines.” Now, that’s more like it.

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