Summary
The House and Senate both return next Monday, September 9. During this Congressional break, we are taking the opportunity to provide in-depth analysis of policies under consideration for a potential lame duck package, which will culminate with the release of the Impact Health Policy Partners Lame Duck memo next week and an Election Preview memo in early October. This week, we focus on Advance Premium Tax Credits and Medicaid program integrity.
Advance Premium Tax Credits
Congress will soon need to consider an extension of the Advanced Premium Tax Credits (APTC), which expire at the end of December 2025. APTCs currently help more than 19 million eligible individuals and families purchase health insurance through the Health Insurance Marketplace. Enhancements to APTCs were first put into place under the American Rescue Plan Act of 2021 (ARPA, P.L. 117-2), and were then extended through 2025 by the Inflation Reduction Act of 2022 (IRA, P.L. 117-169). The intention is to improve the affordability of Marketplace plans and the combination of enhanced APTCs with intentional outreach has led to historic levels of enrollment under the Biden-Harris Administration: more than 21.4 million people enrolled during the 2024 open enrollment period, a 31% increase compared to 2023. If Congress does not extend or make them permanent, almost all marketplace enrollees will face higher premium costs and 3.8 million will become uninsured, per estimates from the Congressional Budget Office (IHPP summary). The Center on Budget and Policy Priorities offers an in depth state-by-state analysis of how premiums will be impacted if APTCs expire.
Congressional Republicans have been very vocal in their opposition to extending enhancements. For Democrats and the Biden-Harris Administration, APTCs are a key element of their efforts to make access to health care and health coverage affordable. While Democrats would prefer to make APTCs permanent, it is more likely that they will be extended during the Lame Duck and the debate over permanency will be punted to later in 2025 when Congress debates the larger tax package.
Medicaid Program Integrity
Earlier this year, the House considered proposals to address improper payments in Medicaid and Medicare as well as policy solutions to improve program integrity. Republicans have been critical of the Center for Medicare & Medicaid Services (CMS’) leadership in managing improper payments, calling for the agency to do more to ensure the accuracy of beneficiary address information as well as prevent fraudsters from using national provider identifiers (NPIs) of deceased providers to submit fraudulent payments. Members of the Energy & Commerce Committee found unanimous bipartisan agreement on five pieces of legislation, advancing all to the House floor during a June markup:
- An amendment in the nature of a substitute (AINS) for H.R. 8084, LIVE Beneficiaries Act
- H.R. 8089, Medicare and Medicaid Fraud Prevention Act of 2024
- An AINS for H.R. 8111, To amend title XIX of the Social Security Act to ensure the reliability of address information provided under the Medicaid program
- An AINS H.R. 8112, To amend title XIX of the Social Security Act to further require certain additional provider screening under the Medicaid program
- An AINS for H.R. 4758, Accelerating Kids’ Access to Care Act
Despite the bipartisan nature of the bills advanced in the House, it remains to be seen if they will receive similar bipartisan support in the Senate, which has instead focused on proposals to modernize care delivery in Medicare and Medicaid.
Regulatory Update
The Office of Management and Budget (OMB) is reviewing the following rules:
Medicare
- Fraud – The final rule would modify the Medicare Shared Savings Program (Shared Savings Program) regulations to address the impact of significant anomalous billing patterns on performance year (PY) 2023 Accountable Care Organization (ACO) financial reconciliation (no date).
Medicaid
- Drug Rebate Program – The final rule would establishes requirements related to manufacturers’ misclassification of covered outpatient drug products under the Medicaid Drug Rebate Program (MDRP). In addition, it finalizes beneficiary protections, as well as MDRP program integrity and administration changes (June 2024).
Private Insurance
- ACA Marketplace – The proposed rule would set payment parameters and provisions related to the risk adjustment programs; cost-sharing parameters; and user fees for issuers offering plans on Federally-facilitated Exchanges and State-based Exchanges using the Federal platform. It would also provide additional standards for several other ACA programs (September 2024).
Other Topics
- Mental Health Parity – The final rule would clarify plans’ and issuers’ obligations under the Mental Health Parity and Addiction Equity Act (MHPAEA) and implement new requirements (July 2024).
- Organ Procurement – The proposed rule would make clarifications and technical modifications to the standards used to evaluate and recertify organ procurement organizations (OPOs) and to the competition and decertification process for organ procurement organizations (March 2025).
- Healthcare System Resiliency and Modernization – The proposed rule would revise and update national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers (was set for December 2023).
- Retail Pharmacy Standards – The final rule would require pharmacies and vendors to modify the currently adopted National Council for Prescription Drug Programs (NCPDP) standards to the Telecommunications Standard Implementation Guide Version F6 (F6); Batch Standard Implementation Guide version 15; and Batch Standard Subrogation Implementation Guide version 10 (was set for February 2024).