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ePolicy News July 2014

Thursday, July 10, 2014




CY 2015 Medicare Physician Fee Schedule Released, Estimated to have a Positive Impact on Pathologists and Laboratories

After years of drastic cuts to reimbursement, CMS takes a less aggressive approach to Medicare payment reform… Big data, information transparency, and stakeholder involvement are key asks of the provider community in this year’s proposed rule.

On July 3, 2014, the Centers for Medicare and Medicaid Services (CMS) released the CY 2015 Medicare Physician Fee Schedule (PFS) and Clinical Laboratory Fee Schedule (CLFS) Proposed Rule, outlining proposed payment rate and policy changes impacting physician and laboratory reimbursement for Medicare Part B services, beginning Jan. 1, 2015.

Regarding its impact on the laboratory and pathology community, this year’s Proposed Rule is rather unique for the following reasons:

1.)    Overall Economic Impact on Pathologists and Laboratories is POSITIVE: Over the past few years, the pathology and laboratory community have endured or, at the very least, been threatened by dramatic cuts to reimbursement via the payment rates and policies proposed and/or finalized in the annual PFS/CLFS. However, this year, the overall impact on pathologists is actually rather favorable, estimated at one percent ($1.07 billion) of total Medicare Part B allowed charges. Similarly, the overall impact on independent laboratories is estimated at three percent ($703 million) of total allowed charges. Conversely, last year’s estimated impacts were -5 percent and -26 percent, respectively.

2.)    Omitted Policy May be of Greater Significance than Policies Actually Included: In a major and unexpected victory for the laboratory and pathology community, CMS did not revisit the “OPPS Cap Proposal,” as it previously stated that it had intended to do in last year’s PFS Final Rule. Under the proposal, CMS had proposed to cap PFS payment rates at hospital payment rates when the former exceeded the latter for a given service. ASCP adamantly opposed this proposal and, in response, led a very successful e-advocacy campaign, resulting in nearly 10,000 messages to CMS and Congress in opposition to it. ASCP is extremely pleased that CMS has finally realized that the “comparison of OPPS (or ASC) payment amounts to PFS payment amounts for particular procedures is not the most appropriate or effective approach to ensuring that PFS payment rates are based on accurate cost assumptions.” Nonetheless, ASCP notes that although CMS recognizes commenters’ concerns with using OPPS/ASC payment amounts as benchmarks for PFS payment rates, given that they reflect average rates/ relative weights rather than direct cost inputs, the Agency is still interested in using outpatient hospital cost data as a benchmark for pricing non-facility based Medicare services and seeks comment accordingly.

3.)    Significant Legislative Overlap Considerations and Implications: The annual publication of the PFS occurs through the federal government’s regulatory process. It is typically completely separate from the legislative process, though often times CMS’s regulatory authority is restricted by what is “set in statute” via legislation. Hence, Congress’s April 1 passage of H.R. 4302, The Patient Access to Medicare Act, significantly impacts the content of this year’s PFS. First, there is little mention of the -20.9 percent PFS update threatening physicians’ Medicare reimbursement as a result of the Sustainable Growth Rate (SGR) payment formula because PAMA averts this cut through March 2015. Second, PAMA repealed CMS’s authority to revalue the CLFS payment rates based on technological change, as previously finalized in last year’s PFS Final Rule, and replaced the revaluation process with a market-based approach that relies on the collection of test-specific price and volume information from private sector payors. Hence, CMS does not touch upon this now statutory-based proposal in this year’s PFS. Additionally, PAMA established nine additional categories for review when identifying potentially misvalued codes, which may have significant additional impact on the type and number of codes up for review when added to the existing seven categories.

4.)    Unprecedented Transparency and Stakeholder Involvement in Payment Rate-Setting: This year, CMS is placing unprecedented emphasis on large-scale, cost-based data collection and payment rate-setting transparency. Accordingly, in lieu of merely dictating changes to payment rates that have already been decided upon behind closed doors, the Agency is exerting its newly enhanced information collection authority via PAMA and reforming its existing timeline for misvalued code nominations and proposals to improve information transparency and increase opportunity for stakeholder input. As such, beginning with the CY 2016 PFS Proposed Rule, CMS will include all CMS-proposed values and all values proposed by the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) that have been received by Jan. 15, 2015. Values proposed by the RUC, but not received by CMS by this date, will be delayed for consideration for one year and included in the following year’s PFS Proposed Rule in order to allow sufficient time for public comment.

Key Provisions Impact the Pathology and Laboratory Community in the CY 2015 PFS Proposed Rule:

Local Coverage Determination Process for Clinical Diagnostic Laboratory Testing

In this proposal, CMS responds to PAMA’s specification that local coverage decisions (LCDs) are to be the mandated vehicle for local coverage policies for clinical diagnostic laboratory tests. Recognizing the need for immediate reform, CMS addresses the challenges experienced throughout the recent molecular pathology valuation process and looks to the National Coverage Determination (NCD) process as a more efficient model for an expedited LCD process. Accordingly, while CMS believes some key aspects of the LCD process should be maintained, such as allowing public comment to draft LCDs, and MAC responses to public comments, the Agency believes there is significant opportunity for streamlining it. The goal of this proposal is to balance the need to allow enough time for notification of stakeholders and public dialogue with the need to finalize a large number of LCDs in a timely manner in order to expedite beneficiary access to covered clinical diagnostic laboratory tests. Reference page 228 of the CY 2015 PFS Proposed Rule: Table 18 Comparison of Current LCD Process versus Proposed LCD Process for Clinical Diagnostic Laboratory Tests below.

Potentially Misvalued Codes:

Flowcytometry/tc add-on: CMS has identified 65 codes as a prioritized subset of potentially misvalued codes of the newly established statutory category finalized with the passage of PAMA, entitled “codes that account for the majority of spending under the PFS.” The majority of spending is defined as greater than or equal to $10 million in allowed charges. Accordingly, only one pathology code was identified via this methodology: CPT Code- HCPCS 88185, Flowcytometry/tc add-on. Nonetheless, CMS actually proposes to increase reimbursement for this code by 5.3 percent (1.5à1.58 RVUs) this year, as proposed in the CY 2015 PFS Proposed Rule’s Addendum B – Relative Value Units and Related Information.

Prostate Biopsy Codes – HCPCS codes G0416, G0417, G0418, and G0419: Based on CMS’s argument that the number of specimens associated with prostate biopsies is relatively homogenous, the Agency is proposing to eliminate all of the g-codes except for G0416, which assumes the lowest number of specimens evaluated for prostate biopsies (10-20 specimens/biopsy). Based on review of medical literature and claims data, CMS maintains that the appropriate number of specimens reviewed per biopsy is typically between 10 and 12. Therefore, the Agency is proposing G0416 as a potentially misvalued code and seeks comment on the appropriate work RVUs, work time, and direct practice expense (PE) inputs. Currently, G0416 is paid at $651.26.

Physician Quality Reporting System (PQRS)

This year, CMS’s proposals focus primarily on the CY 2017 payment adjustment, based on the CY 2015 reporting period, as well as the Agency’s efforts to align quality reporting programs, specifically through the Qualified Clinical Data Registry (QCDR) reporting mechanism. It should be noted that since CY 2014 was the last reporting period in which EPs could earn an incentive payment, quality reporting requirements for the CY 2015 reporting period are focused solely on avoiding application of the -2 percent CY 2017 payment adjustment. Lastly, in this proposed rule, CMS seeks comments broadly regarding whether or not the Agency should allow more frequent submission of data, such as quarterly or year-round submissions, rather than having only one opportunity to submit quality measures data as is the case under the current process.

Other key changes to PQRS for CY 2015 are as follows:

  • CMS proposes three additional pathology-specific measures

  • CMS requires achievement of CY 2014 requirements for achieving a PQRS incentive payment in order to fulfill CY 2015 requirements for avoiding a negative payment adjustment (in CY 2017)

  • CMS introduces an additional reporting requirement for EPs reporting via claims or registry that have at least one face-to-face encounter; they must report on at least two cross-cutting measures

  • CMS pushes the group practice registration deadline from Sept. 30 of the reporting period year to June 30 of the reporting period year

  • CMS specifies that all group practices must report measures on 248 patients (rather than 411 patients for groups of 100+ EPs or 218 patients for groups of 25-99 EPs)

  • Though CMS will no longer fund reporting, CMS proposes to require all groups of 100+ EPs to report the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS survey measures. Reporting these measures remains optional for groups of 2-99 EPs in CY 2015

  • CMS proposes to increase the number of non-PQRS measures allowed for reporting via a QCDR from 20 to 30

  • CMS proposes that QCDRs make available to public its EPs’ quality measures data in CY 2015

  • CMS proposes to allow an entity that uses an external organization for purposes of one or more QCDR functions to still qualify as a QCDR as long as it has a signed agreement with the external entity as of Jan. 1 of the year prior for which it wishes to become a QCDR

  • CMS proposes to extend the deadline for QCDRs to submit quality measures data calculations and results from the last Friday two months after the end of the reporting period to March 31 following the end of the applicable reporting period

Value-Based Payment Modifier Program

CMS proposes to increase the amount of payment at risk under the Value-based Payment Modifier (VBM) program from +/-2 percent in CY 2016 (based on the CY 2014 reporting period) to +/-4 percent in CY 2017 (based on the CY 2015 reporting period). As required by statute, beginning in CY 2017, based on the CY 2015 reporting period, CMS will begin applying the value modifier to physicians in groups of physicians with two or more EPs and to physicians who are solo practitioners. Solo practitioners are defined as a single Tax Identification Number (TIN) with one EP who is identified by an individual National Provider Identifier (NPI) billing under the TIN. Similarly, though not required by statute, CMS will also begin applying the value modifier to non-physician practitioner EPs in groups of two or more EPs as well as solo non-physician practitioners. Lastly, unlike previous years, CMS will begin applying the value modifier to physicians and non-physician EPs participating in the Shared Savings Program, the Pioneer ACO Model, the CPC Initiative, or other similar Innovation Center models/CMS initiatives starting in CY 2017. Reference Table 55: Eligible Professional/ Physician Group Size Distribution (2012 claims) on page 447 of the CY 2015 Proposed Rule.

Also in the CY 2015 PFS Proposed Rule, CMS proposes the following:

  • Quality-tiering is mandatory for all EPs, however groups of 2-9 EPs and individual EPs will be exempt from downward payment adjustments, regardless of performance

  • Because the two programs have two very methodologically dissimilar approaches to calculating cost benchmarks, CMS proposes that classify the cost composite for the value modifier as “average cost” for groups of EPs participating in ACOs during the payment adjustment year

  • Because CMS is unable to calculate a benchmark for QCDR-developed measures, performance on these measures will not be included in the quality composite score

  • CMS proposes to change the reliability policy with respect to the “all-cause hospital readmissions” measure by increasing the minimum number of measures required to report on the measure from 20 to 200 for CY 2015

  • CMS proposes to establish a deadline of Jan. 31, 2015 for a group to request correction of a perceived error made by CMS regarding its CY 2015 value modifier payment adjustment

Lastly, probably the most significant item within the VBM program section of the CY 2015 Proposed Rule is an item that wasn’t actually formally proposed. CMS is considering including or allowing groups that include hospital-based physicians or solo practitioners who are hospital-based to elect the inclusion of Hospital Value-Based Purchasing (VBP) Program performance in their VM calculation in future years of the program. This consideration is in response to commenters past suggestions, noting that there are limited measures that apply to certain specialties and that those specialties may exercise wide influence over the quality of care provided in a hospital.

For an ASCP-developed summary, containing a more complete description of the provisions within the CY 2015 PFS Proposed Rule with greatest impact on the pathology and laboratory community, click here.

Laboratory Community Urged to Drive Transition into the Next Generation of Health Information Exchange 

Five Years Later, Federal Agencies Realize the Critical Role of Laboratory Professionals in Ensuring the Safe, Robust, and Fully Interoperable Electronic Transfer of Patient Health Information

✓ The Cumulative Meaningful Use (MU) Program payments paid to Eligible Hospitals (EHs) and Eligible Professionals (EPs) as of May 2014[i]... $24 Billion

✓ The Electronic Health Record (EHR) vendor market as of 2012[ii]... $20 Billion

✓ The government investment in the establishment of Health Information Technology (HIT) Regional Extension Centers... $677 Million[iii]

✓ The estimated cumulative opportunity cost Incurred by pathologists due to their inability to participate in the MU Program from onset through 2014[iv]...$530 Million

✓ The estimated cumulative cost incurred by Public Health Agencies (PHAs) to enable Electronic Laboratory Result (ELR) transactions... $50-75 Million

✓ The estimated annual cost incurred by laboratories to provide patients with direct access to their laboratory test results in 2013[v]...$3-63 Million

✓ The average cost of developing an EHR per clinician... $54,000

✓ The average annual maintenance cost per EHR per clinician... $20,610

✓ The cost of electronic data transmission fees incurred by laboratories per each laboratory test order... $1[vi]

That moment when the Federal Government finally realizes the essential role of the laboratory community in ensuring the MU program's successful transition from a mere quality reporting to a quality improvement program... PRICELESS

Despite the laboratory community’s substantial financial contributions aiding in the facilitation and acceleration of the meaningful use of EHRs, as indicated above, pathologists have remained essentially ineligible to participate in the MU program since its onset in 2011. Accordingly, though CMS granted pathologists a formal five-year exemption from the negative payment adjustments set to begin in 2015, the laboratory community is still incurring both opportunity and real cost resulting from their inability to participate in the MU program. To date, pathologists have incurred a cumulative $530 million in opportunity cost and millions more in real cost, given the substantial investments that laboratories have made in EHR systems, interfaces, and general interoperability on behalf of their referring clinician offices.

Yet as the Center for Medicare and Medicaid Services (CMS) strives to expand the quantity and diversity of patient health information (PHI) within a patient’s EHR, the Agency is increasingly looking to push and pull additional PHI types to and from a large variety of non-EHR HIT systems across a broad range of clinical settings. Similarly, the Office of the National Coordinator (ONC) is increasingly looking to specialty providers to help shape the policy, certification, and standards development underlying the transmission, incorporation, and utilization of specialty-specific data within an EHR.

Accordingly, two very recently published reports from the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ) highlight the important contributions that laboratory professionals can make to facilitate and accelerate the seamless interoperable exchange of laboratory data both now and in the future.

A Call to Action: Now

In “The Essential Role of Laboratory Professionals: Ensuring the Safety and Effectiveness of Laboratory Data in Electronic Health Record Systems,” the CDC calls upon laboratory professionals to contribute their expertise to the development of accurate exchange and display of laboratory data in EHR systems. CDC defines truly safe and effective data transmission from one type of HIT system to another as follows: “…when the display of information and the computer system behaviors (such as critical results alert) are developed and implemented to optimally ensure accurate and timely interpretation by the end user.”

Further, based on concerns expressed by the Clinical Laboratory Improvement Advisory Committee (CLIAC) that laboratory-related interoperability issues and laboratory data display discrepancies in EHRs may pose a serious threat to patient safety, CDC convened a team of experts to further research the issue. As such, the publication of this white paper is intended to highlight the potential for serious risk to patient safety in the implementation of EHR systems and offer several high-level recommendations to mitigate risk. The three key recommendations, presented jointly by CDC’s Communication in Informatics Workgroup (CIIWG) and CLIAC are presented below:

1.)    Engagement: Provide laboratory expertise for HIT decision-making in the design, development, and implementation (i.e. laboratory data management, exchange, stewardship, and results display)

2.)    Data Integrity and Usability: Ensure that laboratory data are accurately presented in the EHR and available at the point-of-care to reduce laboratory data-related errors (i.e. development of consensus-based information exchange standards in compliance with CLIA regulatory requirements)

3.)    Innovation: Partner with stakeholders to stimulate innovation in EHR technology and usability (i.e. data analytics and clinical decision support driving improved patient outcomes)

For a chart listing each recommendation’s associated root issue, key action items, suggested strategies, and relevant resources, click here.

A Call to Action: Future

In April 2014, the MITRE Corporation, a not-for-profit national technology resource that provides systems engineering, research and development, and information technology support to the government, prepared a report for AHRQ, entitled “A Robust Health Data Infrastructure.” The report hypothesized the future landscape of HIT, identifying the possible benefits of advanced health information exchange (HIE), proposing innovative software architecture, and predicting the EHR data types of the future. In particular, this report suggests that improved HIE and a more comprehensive picture of patient health via access to a more robust dataset has the potential to: (1) Substantially improve care coordination; (2) Enhance patient access; (3) Reduce errors within and across patient records; (4) Reduce redundant testing and diagnostic procedures; (5) Enable longitudinal tracking of individual and population health; (6) Reinforce standards of care to mitigate clinical errors; (7) Inform biomedical research; (8) Enable automated, electronic detection of fraud; and (9) Improve tracking of healthcare costs and benefits to instill a better understanding of the healthcare economics underlying service delivery.

Moreover, in order to fully realize the potential benefits listed above, the report offers a proposal for the ideal software architecture, suggesting the following core principles:

  • Be agnostic as to the type, scale, platform, and storage location of the data
  • Use public Application Program Interfaces (APIs) and open standards, interfaces, and protocols
  • Encrypt data at rest and in transit
  • Separate key management from data management
  • Include with the data the corresponding metadata, context, and provenance information
  • Represent the data as atomic data with associated metadata
  • Follow the “robustness principle”: be liberal in what you accept and conservative in what you send

Lastly, the report hypothesizes that the “EHR data types of the future” will include genomic data (“omic” data), expression data, patient-reported data from embedded and wireless sensors, and population health data gleaned from open-sources. In particular, the report identifies the following “omic” data and their perceived future benefits for enhancing the provider’s understanding of patient condition:

  • Genome Sequence: to capture all of the genetic variation of an individual in comparison to the reference human genome sequence
  • Transcriptome: Similar to a genome sequence but further captures variables of cell state, thereby generating larger and more personalized datasets
  • Epigenome: Allows for spatial resolution of particular modifications in the genome
  • Proteome: Describes the types and amounts of proteins expressed from the genome
  • Microbiome: Offers a complete description of the human body’s microbial cells, which allows for the potential detection and correction of aberrant states linked to pathogenic conditions
  • Immunome: A description of the state of the immune system of an individual, focusing on the diversity of immune responses based on past exposures; high-throughput methods now allow testing for reactivity to thousands of antigens at once

Sylvia Mathews Burwell Confirmed as Secretary of Health and Human Services

Sylvia Mathews Burwell was confirmed as the new Secretary of Health and Human Services (HHS)  on May 22. Transitioning from her role as the Director of the Office of Management and Budget (OMB), she enters the HHS with experience in both the private and public sector.

An overwhelming majority of 78-17 confirmed her nomination and Senate Republicans are hopeful that Burwell will be open to hearing their concerns regarding the highly polarizing Affordable Care Act. Following the resignation of her predecessor, Kathleen Sebelius, she faces tremendous pressure to improve implementation of the ACA at the state level and online. With her ability to inspire bipartisan support and impressive credentials, Burwell is well positioned to accomplish these challenging tasks.



CMS to Cover HCV Screening

The Centers for Medicare & Medicaid Services (CMS) announced on June 2 that Medicare and Medicaid will cover screening for Hepatitis C virus (HCV). CMS's recent determination to cover HCV screening is consistent with the recommendations by the U. S. Preventive Services Task Force. CMS indicated that it will cover screening for HCV with the appropriate U. S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the beneficiary's primary care physician or practitioner within the context of a primary care setting and performed by an eligible Medicare provider for these services, for beneficiaries who meet either of the following conditions:

  1. A screening test is covered for adults at high risk for Hepatitis C Virus infection. "High risk" is defined as persons with a current or past history of illicit injection drug use and persons who have a history of receiving a blood transfusion prior to 1992. Repeat screening for high-risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test.
  2. A single screening test is covered for adults who do not meet the high risk as defined above, but who were born from 1945 through 1965.

CMS stated in a national coverage decision that "the evidence is adequate to conclude that screening for Hepatitis C Virus (HCV), consistent with the grade B recommendations by the U. S. Preventive Services Task Force (USPSTF), is reasonable and necessary for the prevention or early detection of an illness or disability and is appropriate for individuals entitled to benefits under [Medicare] Part A or enrolled under Part B."

Previously in 2012, the U. S. Centers for Disease Control and Prevention (CDC) also recommended that all Baby Boomers, those born between 1945 and 1965, should have a one-time blood test to screen for HCV, which often goes undetected and can take years to cause serious illness. Untreated, HCV can eventually cause liver disease and liver cancer.

New Genetic Test Diminishes Risk for Transfusion Reaction

Medical diagnostic technology is continuously improving the precision of test results and providing targeted diagnosis and treatment. While the healthcare industry is moving closer to the personalized medicine standard of care, advancements in test specificity require adequate justification for their utilization. In particular, the justification for a closer matched unit of blood in the blood banking industry using genotype testing was at the heart of the discussion at recent Capitol Hill briefing entitled “Blood Safety: The Importance of Diagnostics and Devices.”

Under current serologic testing, one to five percent of patients mount an immune response to infused blood. However, certain subgroups, such as those with Sickle Cell Disease or individuals with bone marrow failure, may develop certain conditions which result in reliance upon chronic infusions. Of those chronically-infused patients, between 12 and 39 percent mount an antibody response to traditionally cross-matched blood.

To provide adequately matched blood to these populations, Immucor presented a genetic test which identifies 35 clinically significant antigens at the AMA Pathology Coding Caucus. This test was granted PMA approval and the CPT tier 2 code 81403 will be active July 1, 2014.


HRSA Announces Formation of the Bureau of Health Workforce

The Health Resources and Services Administration (HRSA) announced the formation of a new bureau, the Bureau of Health Workforce (BHW). This bureau will now oversee the programs administered by the Bureau of Health Professions and the Bureau of Clinician Recruitment and Service.  Led by Associate Administrator Rebecca Spitzgo, BHW will help HRSA achieve its mission of improving health and achieving health equity through access to quality services, a skilled health workforce and innovative programs.

According to BHW, the programs and activities will be implemented to:

  • Train the next generation of diverse healthcare providers to serve underserved populations through its grants to health professions schools and training programs.

  • Examine a broad range of issues that impact the supply, demand, distribution, and education of the Nation’s health workforce and provide policymakers with the information necessary to make informed decisions regarding the health professions workforce and provision of care.

  • Support graduate medical education.

  • Recruit and retain providers and students to underserved areas through both the National Health Service Corps and NURSE Corps Scholarship and Loan Repayment Programs.

  • Protect the public from healthcare practitioners, providers, and suppliers with a history of malpractice, adverse actions, fraud and abuse through the National Practitioner Data Bank.


This restructuring will allow for increased connectivity between programs and with particular focus on the distribution of the health workforce. To prepare for the influx of newly-covered individuals under the ACA, the bureau will provide informational materials to be distributed to patients. Topics include when and where to seek care and the importance of prevention and a steady healthcare provider. Materials are available at the coverage to care website and can also be found at  For more information, visit the BHW website at:



New Global AIDS Coordinator Outlines Next Phase for PEPFAR

The key to delivering an AIDS-Free Generation, according to Ambassador Deborah L. Birx, MD, the New Global AIDS Coordinator, is “delivering the right thing in the right place at the right time.” Ambassador Birx shared her vision for the next phase of the U. S. President’s Emergency Plan for AIDS Relief (PEPFAR) to support efforts for an AIDS-free generation during a recent town hall event hosted by the Kaiser Family Foundation.

By “the right things,” Ambassador Birx referred to the core PEPFAR activities, those critical to saving lives and preventing new infections. These high-impact interventions include prevention activities, support services for orphans and vulnerable children as well as neglected and/or hard to reach populations, and strengthening health systems to specifically support these interventions. Equally important is ensuring these interventions are geographically focused and reaching the most vulnerable populations in an effective way. And finally, the timing of these interventions will be critical to PEPFAR’s success by preventing new infections among the most vulnerable populations and in the highest prevalence areas. Ambassador Birx also promised greater accountability through cost-effective programming designed to maximize impact of every dollar invested and transparency through validation and sharing of all levels of program data.

Through PEPFAR, ASCP Global Outreach has been working around the world since 2005 to improve laboratory quality and patient health outcomes. ASCP staff and consultants have facilitated more than 120 trainings, workshops, and mentorships and trained more than 2,200 laboratory professionals and medical laboratory instructors worldwide. These activities have comprised subject-specific, hands-on trainings as well as university curriculum improvement, teacher trainings, and laboratory accreditation and quality improvement projects.



Demystifying the Logic of the ACA: From Eligibility to Coverage to Care

Fifty-six percent of America’s uninsured may be eligible for coverage under the Affordable Care Act (ACA), but it is estimated that half of the uninsured in expansion states and one-third of the uninsured in non-expansion states will actually enroll, according to a new report from the Robert Wood Johnson Foundation (RWJF).

With significant differences in eligibility based on a state’s decision to expand Medicare coverage, 68 percent of the uninsured became eligible for assistance in expansion states, compared to only 44 percent in non-expansion states. Texas, Mississippi, Louisiana, and Georgia currently hold the lowest shares of eligibility for assistance under the Affordable Care Act (ACA). Unfortunately, these regions also have large share of residents who fall into a coverage gap; this comprises individuals whose income is below 100 percent of the federal poverty level but remain ineligible for assistance due to their state’s opt-out of Medicaid expansion. An outlier in this trend is the non-expansion state of Wisconsin, which will have 75 percent of its uninsured residents eligible for assistance. However, this is the result of a recent change in Wisconsin’s Medicaid waiver which expanded Medicaid eligibility to adult non-parents. In contrast, Massachusetts is an expansion state which has already implemented its own health reform law to expand coverage and will thus largely be unaffected by the ACA. For more state-specific statistics, please refer to Eligibility Assistance and Projected Changes in Coverage Under the ACA: Variation Across States by the RWJF.

Eligibility and coverage predictions for the uninsured are important indicators for care delivery, but do not directly correlate with the percentage of individuals who will truly receive appropriate care under the ACA. Education regarding the utilization of our healthcare system once enrolled is an essential component in the implementation of the ACA and will require adaptation from both patients and providers. To aid in this transition, the Centers for Medicare and Medicaid Services (CMS) launched its "From Coverage to Care" initiative on June 16 to answer questions and inform newly-enrolled individuals of the preventative and primary care services available in their communities.


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