Health Secretary Robert F. Kennedy Jr. on Thursday faced federal lawmakers for the first time since September as he sought to defend a more than 12% proposed cut to his department’s budget and dodge arrows from angry Democrats along the way.

In his testimony before the House Ways and Means Committee, kicking off an expected sprint of seven budget hearings he’ll attend across congressional committees and subcommittees over the next week, Kennedy emphasized the administration’s work to reform dietary guidelines and crack down on waste, fraud and abuse.

Republicans on the committee praised Kennedy as a “breath of fresh air” and asked him to promote his department’s recent actions. Democrats, who have been furious over Kennedy’s sweeping overhaul of the U.S. Department of Health and Human Services, largely had a different agenda.

They needled Kennedy on what they viewed as the Trump administration’s hypocrisy on fraud, demanded to know why he was cutting budgets for various programs and slammed his efforts to pull back vaccine recommendations and messaging, which they said have caused unnecessary deaths.

Kennedy fired back, often raising his voice as he accused the Democrats of misrepresenting his work and past statements.

Here are three standout moments from Thursday’s hearing:

A standoff over measles

One heated exchange early in the hearing came between Kennedy and Rep. Linda Sanchez. The California Democrat decried recent measles outbreaks across the U.S. and asked Kennedy to answer for the fact that under his leadership, the Centers for Disease Control and Prevention pulled back public health messaging supporting vaccination.

“As a mother, this horrifies me,” Sanchez said. “Did President Trump approve your decision to end CDC’s pro-vaccine public messaging campaign?”

Kennedy repeatedly refused to answer, saying first he wanted to respond to the “misstatements that you’ve made” and later praising the Trump administration’s record on preventing measles, although protections against the disease have eroded in some parts of the country as vaccination rates have dropped.

“That’s not answering my question,” Sanchez said as the two talked over each other.

But Sanchez also got Kennedy, a longtime anti-vaccine activist before he entered politics, to acknowledge that a 6-year-old who died of measles last year in West Texas could have potentially been saved with vaccination.

“Do you agree with the majority of doctors that the measles vaccine could have saved that child’s life in Texas?” she asked.

“It’s possible, certainly,” Kennedy said.

RFK Jr. denies talking about Black children being ‘re-parented’

A fight erupted between Kennedy and Rep. Terri Sewell, a Democrat from Alabama, when Kennedy vehemently denied making remarks he’d said in 2024.

The comments dated back to when Kennedy was a presidential candidate. On the “High Level Conversations” podcast last July, he said, “Psychiatric drugs — which every Black kid is now just standard put on Adderall, SSRIs, benzos, which are known to induce violence, and those kids are going to have a chance to go somewhere and get re-parented to live in a community where there’ll be no cellphones, no screens, you’ll actually have to talk to people.”

“Have you ever re-parented, or parented, I should say, a Black child?” Sewell asked, as her staff held up a poster featuring an abbreviated version of the quote.

“I don’t even know what that phrase means,” Kennedy said. “I’m not going to answer something I didn’t say.”

“You’re making stuff up,” he later claimed.

A recording of the podcast shows he made the comments during a conversation about free rehabilitation facilities he was proposing opening at the time in rural areas around the country.

HHS spokesperson Emily Hilliard said Kennedy before joining the administration was referring to spaces where young people facing alienation, mental health challenges and despair could get re-parented, which she said was a psychotherapy term for “developing the emotional regulation, discipline, boundaries, and self-worth that may not have been established in childhood.”

For Kennedy and his former party, civility is the exception

Kennedy spent most of his life as a Democrat, the scion of one of the nation’s most famous political families. Both Republicans and Democrats during the hearing began their remarks by expressing their admiration of Kennedy’s relatives, among them former President John F. Kennedy.

But again and again throughout Thursday’s hearing, the fraying of bonds between Kennedy and his former party was on full display as spiteful comments were passed back and forth.

The health secretary grew defensive and visibly agitated. He repeatedly criticized Democratic lawmakers for not giving him a word in edgewise.

“They’ve all shut me up,” Kennedy said at one point. “They give a little speech that they can go and market, you know, for fundraising, and they don’t allow me to answer the question.”

On a few rare occasions, the exchanges were civil. One representative, Gwen Moore of Wisconsin, used humor to make that happen.

“I promise to give you easy, comfortable questions if you don’t yell at me and hurt my feelings,” she told Kennedy. He promised he wouldn’t.

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Thanks to President Biden’s new law to lower prescription drug costs, the final rule will also improve access to affordable prescription drug coverage for an estimated 300,000 low-income individuals

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), is finalizing a rule to put people with Medicare first and put strong protections in place so that Medicare Advantage (MA) works for them. This final rule will strengthen Medicare Advantage and hold health insurance companies to higher standards for America’s seniors and people with disabilities by cracking down on misleading marketing schemes by Medicare Advantage plans, Part D plans and their downstream entities; removing barriers to care created by complex coverage criteria and utilization management; and expanding access to behavioral health care. The new rule will also promote health equity, and implement a key provision of the Inflation Reduction Act—President Biden’s new law to lower prescription drug costs—that will improve access to affordable prescription drug coverage for an estimated 300,000 low-income individuals.

The Biden-Harris Administration is committed to protecting and strengthening Medicare for the 65 million people with Medicare today and for future generations. In the past few months, the Department has taken a series of actions to ensure the Medicare Advantage program works for people with Medicare and that private insurance companies are held accountable for providing quality coverage and care:

• In February, CMS finalized a rule to start recovering improper payments made to Medicare Advantage plans through audits for the first time since 2007. Recovering these improper payments and returning this money to the Medicare Trust Funds will protect the fiscal sustainability of Medicare and allow the program to better serve seniors and people with disabilities, today and in the future.
• Last week, CMS finalized policies in the 2024 Medicare Advantage and Part D Rate Announcement to improve payment accuracy and ensure taxpayer dollars are appropriately safeguarded and well-spent.

“At HHS, we put seniors and people with disabilities first,” said HHS Secretary Xavier Becerra. “That is exactly what we are doing today. In our latest effort to strengthen Medicare and hold insurance companies accountable, we are putting protections in place so that Medicare Advantage works for beneficiaries and they get the quality care they deserve. We will continue our efforts to deliver on the President’s vision to strengthen this program for the millions of people with Medicare and for future generations to come.”

“The Biden-Harris Administration has made exceptionally clear that one of its top priorities is protecting and strengthening Medicare,” said CMS Administrator Chiquita Brooks-LaSure. “With this final rule, CMS is putting in place new safeguards that make it easier for people with Medicare to access the benefits and services they are entitled to, while also strengthening the Medicare Advantage and Part D programs.”

“People with Medicare deserve to have access to accurate information when making coverage choices, and to be able to get the care they need without excessive burden or delays,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare. “The commonsense policies in this rule further our goals to advance health equity, improve access to care, and drive high-quality, whole-person care.”

Cracking Down on Misleading Marketing Schemes

The final rule includes changes to protect people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing practices. Ads will be prohibited if they do not mention a specific plan name, or if they use the Medicare name, CMS logo, and products or information issued by the Federal Government, including the Medicare card, in a misleading way. Further, the final rule strengthens accountability for plans to monitor agent and broker activity.

Removing Barriers to Care Created by Complex Prior Authorization and Utilization Management

CMS is also providing important protections regarding utilization management policies and coverage criteria that ensure that Medicare Advantage enrollees receive the same access to medically necessary care that they would receive in Traditional Medicare. The rule streamlines prior authorization requirements and reduces disruption for enrollees by requiring that a granted prior authorization approval remains valid for as long as medically necessary to avoid disruptions in care, requiring Medicare Advantage plans to annually review utilization management policies, and requiring denials of coverage based on medical necessity be reviewed by health care professionals with relevant expertise before a denial can be issued. These policies complement proposals in CMS’ Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P).

Expanding Access to Behavioral Health Care

CMS remains committed to emphasizing the critical role that access to behavioral health plays in whole person care. In line with CMS’ Behavioral Health Strategy and the Administration’s strategy to address the national mental health crisis, CMS is strengthening behavioral health network adequacy in Medicare Advantage by adding clinical psychologists and licensed clinical social workers to the list of evaluated specialties. CMS is also finalizing wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. In addition, CMS is requiring most types of Medicare Advantage plans to include behavioral health services in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning. 

Promoting More Equitable Care

Additionally, CMS is advancing health equity and driving quality in health coverage by establishing a health equity index in the Star Ratings program that will reward Medicare Advantage and Medicare Part D plans that provide excellent care for underserved populations. Plans will also be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency, through newly expanded requirements for providing materials in alternate formats and languages. The final rule balances patient experience/complaints measures, access measures, and health outcomes measures in the Star Ratings program to more effectively focus both on patient-centric care and on improving clinical outcomes.

Implementing President Biden’s New Prescription Drug Law

The final rule also implements a key provision of the Inflation Reduction Act that improves access to affordable prescription drug coverage for approximately 300,000 low-income individuals. As outlined in President Biden’s new prescription drug law, CMS is expanding eligibility for the full low-income subsidy benefit (also known as “Extra Help”) to individuals with incomes up to 150% of the federal poverty level who meet eligibility criteria. Beginning January 1, 2024, this change will provide the full low-income subsidy to those who would currently qualify for the partial low-income subsidy. As a result of this change, eligible enrollees will have no deductible, no premiums (if enrolled in a “benchmark” plan), and fixed, lowered copayments for certain medications under Medicare Part D.

View a fact sheet on the final rule.

The final rule can be accessed from the Federal Register at: https://www.federalregister.gov/public-inspection/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program.

Medicare Advantage Value-Based Insurance Design Model Extension

Additionally, today CMS is also releasing more information about the extension of the Center for Medicare and Medicaid Innovation’s Medicare Advantage Value-Based Insurance Design (VBID) Model from 2025 through 2030. This extension will introduce changes intended to more fully address the health-related social needs of patients, advance health equity, and improve care coordination for patients with serious illness. View the fact sheet, and more information, on the model webpage.

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The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), proposed a rule to strengthen Medicare Advantage and Medicare Part D prescription drug coverage for the tens of millions of people who rely on the programs for health care coverage. The proposed rule improves protections for people with Medicare, expands access to behavioral health care, and promotes equity in coverage. The proposed rule also implements a key provision of the Inflation Reduction Act to make prescriptions drugs more affordable for approximately 300,000 low-income individuals who will benefit in 2024.

“We are taking feedback from thousands of Americans and turning it into concrete action to strengthen Medicare for the millions of Americans who rely on it,” said HHS Secretary Xavier Becerra. “From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the health care they need.”

“We continue working tirelessly to implement President Biden’s Inflation Reduction Act. Today, thanks to the new law, we are taking action to lower costs and expand access to affordable prescription drug coverage for hundreds of thousands of people with Medicare, including communities of color and those living on fixed incomes,” the Secretary continued.

“CMS released a proposed rule today that takes important steps to hold Medicare Advantage plans accountable for providing high quality coverage and care to enrollees,” said CMS Administrator Chiquita Brooks-LaSure. “The rule also strengthens Medicare prescription drug coverage and implements an important provision of the Inflation Reduction Act to help more people with Medicare who have modest incomes afford their prescriptions.” 

A July 2022 Request for Information on Medicare Advantage drew almost 4,000 comments regarding improvements to the program. We thank stakeholders for their thoughtful feedback, and the policies in this proposed rule are informed by the feedback received.

In this rule, CMS proposes significant changes to strengthen protections for people enrolled in or seeking coverage from Medicare Advantage plans or Medicare Part D prescription drug plans, including through improvements to prior authorization, coverage guidelines, and plan marketing requirements. The rule proposes clarifications and revisions to regulations governing when and how Medicare Advantage plans develop and use coverage criteria and utilization management policies to ensure Medicare Advantage enrollees receive the same access to medically necessary care they would receive in Traditional Medicare. The rule also proposes policies to streamline prior authorization requirements and reduce disruption for enrollees. It does this by requiring that a granted prior authorization approval remain valid for an enrollee’s full course of treatment, requiring Medicare Advantage plans to annually review utilization management policies, and requiring coverage determinations be reviewed by professionals with relevant expertise. These proposed policies complement proposals in CMS’ recently announced Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P).

Additionally, the proposed rule focuses on protecting people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing while also ensuring access to accurate and necessary information to make coverage choices. The proliferation of certain television advertisements generically promoting Medicare Advantage enrollment has been a topic of concern. To address this, CMS proposes to prohibit ads that do not mention a specific plan name as well as ads that use words and imagery that may be confusing, or use language or logos in a way that is misleading, confusing, or misrepresents the plan. CMS also proposes to codify guidance protecting people with Medicare or exploring Medicare coverage from misleading marketing and ensure they are not pressured into enrolling into plans that may not best meet their needs. Further, CMS is proposing to strengthen the role of plans in monitoring agent and broker activity.

“People exploring Medicare coverage options deserve peace of mind that they are receiving honest, transparent, and accurate information about health coverage options and have access to the care they need. These proposed protections are commonsense and critical to the physical, mental, and financial stability of millions of people who choose a Medicare coverage option each year,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare.

CMS remains committed to emphasizing the invaluable role that access to behavioral health plays in whole person care. In line with CMS’ Behavioral Health Strategy and the Administration’s strategy to address the national mental health crisis, CMS proposes to strengthen behavioral health network adequacy by adding clinical psychologists, licensed clinical social workers, and prescribers of medication for opioid use disorder to the list of evaluated specialties. CMS also proposes new minimum wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. Finally, CMS proposes to require most types of Medicare Advantage plans include behavioral health service in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning. 

Additionally, the proposed rule reinforces CMS’ commitment to advancing health equity and driving quality in health coverage. For the first time, CMS proposes establishing a health equity index in the Star Ratings program that would reward excellent care for underserved populations by Medicare Advantage and Medicare Part D plans. The rule also proposes updates to the Medicare Part D medication therapy management (MTM) program to improve access, including a proposed requirement that plans include all 10 core chronic diseases identified by CMS — including HIV/AIDS — in their MTM targeting criteria. Plans would also be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency, through newly proposed interpreter standards and the requirement that materials be provided in alternate formats and languages. Finally, the proposed rule would balance the emphasis between patient experience, complaints, and access Star Ratings measures and health outcomes Star Ratings measures to more effectively focus both on patient-centric care and on improving clinical outcomes.

In order to implement section 11404 of the Inflation Reduction Act (Pub. L. 117-169), CMS proposes to expand eligibility under the low-income subsidy (LIS) program. Under the IRA provision and proposal, individuals with incomes up to 150% of the federal poverty level and who meet statutory resource requirements will qualify for the full LIS beginning on or after January 1, 2024. This change will provide the full LIS to those who would currently qualify for the partial LIS, improving access to affordable prescription drug coverage and lowering costs. As a result of this change, eligible enrollees will have no deductible, no premiums (if enrolled in a “benchmark” plan), and fixed, lowered copayments for certain medications.

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Increasing Access to Health Care Services

Network Adequacy and Essential Community Providers

CMS proposes to revise the network adequacy and essential community provider (ECP) standards to provide that all individual market qualified health plans (QHPs), including stand-alone dental plans (SADPs) and all Small Business Health Option Program (SHOP) plans across all Marketplace-types must use a network of providers that complies with the network adequacy and ECP standards in those sections, and to remove the exception that these sections do not apply to plans that do not use a provider network. Requiring that all QHPs use a provider network would better ensure consumer access to a sufficient choice of providers and would guarantee consumers have access to information on the availability of in-network providers.

CMS also proposes to expand access to care for low-income and medically underserved consumers by establishing two additional major ECP categories for Plan Year (PY) 2024 and beyond: 1) Mental Health Facilities; and, 2) Substance Use Disorder (SUD) Treatment Centers. Additionally, for PY2024 and beyond, CMS proposes to retain the overall 35% provider participation threshold, and also extend the 35% threshold to two major ECP categories: Federally Qualified Health Centers (FQHCs) and Family Planning Providers. These changes would increase provider choice and access to care for low-income and medically underserved consumers.

Simplifying Choice and Improving the Plan Selection Process

Standardized Plan Options

CMS proposes to make several minor updates with respect to standardized plan options. Specifically, CMS proposes to no longer include a standardized plan option for the non-expanded bronze metal level. Accordingly, CMS proposes that for PY2024 and subsequent PYs, issuers offering QHPs through the Federally-facilitated Marketplace (FFM) and State-based Marketplaces on the Federal platform (SBM-FP) must offer standardized QHP options designed by CMS at every product network type, at every metal level except the non-expanded bronze level, and throughout every service area that they offer non-standardized QHP options. CMS believes maintaining the highest degree of continuity possible in designing these standardized plan options is critical to reduce the risk of disruption for consumers enrolled in these plans.

In addition, CMS proposes that issuers of standardized plan options must: (1) place all covered generic drugs in the standardized plan options’ generic drug cost-sharing tier, or the specialty drug tier if there is an appropriate and non-discriminatory basis; and, (2) place brand name drugs in either the standardized plan options’ preferred brand or non-preferred brand tiers, or specialty drug tier if there is an appropriate and non-discriminatory basis. CMS proposes this specification to reduce the risk of discriminatory benefit designs, to minimize barriers to access for prescription drugs, and to reduce the risk of consumer confusion for those enrolled in these plans.

CMS also proposes to limit the number of non-standardized plan options that issuers of QHPs can offer through Marketplaces on the Federal platform (including SBM-FPs) to two non-standardized plan options per product network type and metal level (excluding catastrophic plans), in any service area, for PY2024 and beyond, as a condition of QHP certification. The average number of plans available to consumers on the Marketplace has increased from 25.9 in PY2019 to 113.6 in PY2023. Such plan choice overload limits consumers’ ability to make a meaningful selection when comparing plan offerings.

Under this proposed requirement, an issuer would, for example, be limited to offering through a Marketplace two gold health maintenance organization (HMO) and two gold preferred provider organization (PPO) non-standardized plan options in any service area in PY2024 or any subsequent PY.

Similar to the approach taken with respect to standardized plan options in the 2023 Payment Notice and in this proposed rule, CMS proposes to not apply this requirement to issuers in State Marketplaces. Further, consistent with the approach taken with respect to standardized plan options in the 2023 Payment Notice and in this proposed rule, since SBM-FPs use the same platform as the FFMs, CMS proposes to apply this requirement equally on FFMs and SBM-FPs. Finally, also in alignment with the approach taken with standardized plan options in the 2023 Payment Notice as well as the approach taken in this proposed rule, CMS proposes that this proposed requirement would not apply to plans offered through the SHOPs or to SADPs.

As an alternative to limiting the number of non-standardized plan options that issuers in FFMs and SBM-FPs can offer through the Marketplaces in order to reduce the risk of plan choice overload, CMS could also apply a meaningful difference standard in PY2024 and subsequent PYs. Under this proposed standard, CMS proposes grouping plans by issuer ID, county, metal level, product network type, and deductible integration type, and then evaluating whether plans within each group are “meaningfully different” based on differences in deductible amounts. With this proposed approach, two plans would need to have deductibles that differ by more than $1,000 to satisfy the new proposed meaningful difference standard. CMS seeks comment on this alternative proposal.

In conjunction with the requirement for issuers to offer standardized plan options, having a more manageable number of plan choices for consumers to select from would further streamline the plan selection process and facilitate more meaningful evaluation of available plan choices, which would also allow consumers to more easily select a health plan that best fits their unique health needs.

Stand-Alone Dental Plans (SADPs)

CMS proposes to require issuers of SADPs, as a condition of Marketplace certification, to use age on effective date as the sole method to calculate an enrollee’s age for rating and eligibility purposes beginning with Marketplace certification for PY2024. CMS proposes that this requirement apply to Marketplace-certified SADPs, whether they are sold on- or off-Marketplace. Requiring SADPs to use the age on effective date methodology to calculate an enrollee’s age as a condition of QHP certification, and consequently removing the less commonly used and more complex age calculation methods, would reduce consumer confusion and promote operational efficiency.

CMS also proposes to require issuers of SADPs, as a condition of Marketplace certification, to submit guaranteed rates beginning with Marketplace certification for PY2024. CMS proposes that this requirement apply to Marketplace-certified SADPs, whether they are sold on- or off-Marketplace. This policy change would help reduce the risk of incorrect advance payments of the premium tax credit (APTC) calculation for the pediatric dental essential health benefit (EHB) portion of premiums, thereby reducing the risk of consumer harm.

Re-enrollment Hierarchy

CMS proposes to allow Marketplaces, beginning for PY2024, to modify their automatic re-enrollment hierarchies such that enrollees who are eligible for cost-sharing reductions (CSRs) and who would otherwise be automatically re-enrolled in a bronze-level QHP without CSRs, to instead be automatically re-enrolled in a silver-level QHP (with CSRs) in the same product with a lower or equivalent premium, provided that certain conditions are met. Furthermore, we propose to amend the Marketplace re-enrollment hierarchy to allow all Marketplaces (Marketplaces on the Federal platform and SBMs) to ensure enrollees whose QHPs are no longer available to them and enrollees who would be re-enrolled into a silver-level QHP in order to receive income-based CSRs are re-enrolled into plans with the most similar network to the plan they had in the previous year, provided that certain conditions are met. We propose that Marketplaces (including Marketplaces on the Federal platform and SBMs) would implement this option beginning with the open enrollment period for plan year 2024 coverage, if operationally feasible, and if not then beginning with the open enrollment period for PY2025 coverage.

Establish Requirements for Qualified Health Plan and Plan Variant Marketing Names

CMS proposes to require that QHP plan and plan variant marketing names include correct information, without omission of material fact, and do not include content that is misleading. This proposal will help consumers applying for coverage to understand references to benefit information in plan and plan variant marketing names, and to use this information to make an informed plan selection.

If finalized as proposed, CMS would review plan and plan variant marketing names during the annual QHP certification process in close collaboration with State regulators in States with Marketplaces on the Federal platform. 

Making It Easier to Enroll in Coverage

Special Enrollment Periods

CMS proposes that beginning January 1, 2024, that Marketplaces have the option to implement a new special rule for consumers losing Medicaid or Children’s Health Insurance Program (CHIP) coverage that is also considered minimum essential coverage (MEC). This special rule would mean that consumers would have 60 days before, or 90 days after, their loss of Medicaid or CHIP coverage to select a plan for Marketplace coverage via a special enrollment period (SEP). Marketplaces would have additional flexibilities to decide whether to offer this special rule or not, depending on eligibility and/or enrollment trends for their respective populations. CMS believes that this new proposed special rule would help mitigate coverage gaps when consumers lose Medicaid or CHIP while allowing for a more seamless transition into Marketplace coverage. 

CMS also proposes to change the current coverage effective date requirements so that Marketplaces have the option to offer earlier coverage effective start dates for consumers attesting to a future loss of MEC and who would otherwise experience gaps in coverage effective as of the date of the final rule. CMS believes that these changes would ensure qualifying individuals are able to seamlessly transition from other forms of coverage to Marketplace coverage as quickly as possible with no coverage gaps. For example, if this proposal is finalized as proposed, when a consumer attests between May 16 and June 30 that they will lose other MEC on July 15 and selects a plan on or before June 30, coverage would be effective on July 1. If that consumer selects a plan after June 30, coverage would be effective as of August 1.

CMS also proposes removing consumer burden by aligning the regulations with the policy and operations of the Marketplaces on the Federal platform for granting special enrollment periods (SEPs) to qualified consumers who are affected by a material plan display error with current plan display error SEP operations. Currently, the regulation requires the qualified individual or enrollee, or their dependent, to adequately demonstrate to the Marketplace that a material error related to plan benefits, service area, or premium influenced their decision to purchase a QHP through the Marketplace. However, we have found that consumers may benefit when other interested parties can demonstrate to the Marketplace that a material plan error influenced the enrollment decision to purchase a QHP through the Marketplace.

Income Data Matching Issues

CMS proposes to accept the household’s income attestation when HHS requests tax return data from the Internal Revenue Service (IRS) but such data is not available. Such cases often occur when household composition changes across tax years (marriage, divorce, birth of a child) or if individuals were previously below the filing threshold and did not receive advance payments of the premium tax credits. All individuals receiving advance payments of the premium tax credits are required to file taxes and to reconcile those payments with final annual income. These proposed changes would reduce administrative burden, increase access, and have a positive impact on health equity.

Allow Door to Door Enrollment by Navigators and other Assisters

CMS proposes to permit assisters^[1] to conduct door-to-door enrollment to increase consumer engagement and advance health equity. Assisters currently conduct door-to-door outreach, education, and schedule follow-up appointments, but are prohibited from providing enrollment assistance upon an initial interaction at the consumers’ residence. The prohibition on door-to-door enrollment during the first contact burdens the consumer and assisters and creates access barriers for consumers to receive timely enrollment assistance.

Strengthening Markets

FFM and SBM-FP User Fees

For the 2024 benefit year, CMS proposes to lower the user fee rate from 2.75% to 2.5% of premium for QHPs sold on the FFM, and to lower the user fee rate from 2.25% to 2.0% of premium for QHPs sold on the SBM-FP. We anticipate these user fee rate decreases may exert downward pressure on insurance premiums, resulting in lower costs for consumers.

HHS-Operated Risk Adjustment Program

For the 2024 benefit year risk adjustment models, CMS proposes to use the 2018, 2019, and 2020 enrollee-level EDGE data for model recalibration, with one exception. For the adult models’ age-sex coefficients, CMS proposes to blend only the 2018 and 2019 enrollee-level EDGE data and to exclude the 2020 enrollee-level EDGE data given CMS’ analysis of the 2020 enrollee-level EDGE data and observed anomalous decreases in the unconstrainted coefficients for the 2020 benefit year enrollee-level EDGE recalibration data for older adult enrollees, especially female enrollees. Additionally, CMS proposes to continue to apply a market pricing adjustment to the plan liability associated with Hepatitis C drugs in the risk adjustment models for the 2024 benefit year. CMS also requests comment on whether to add a new payment HCC for gender dysphoria to the risk adjustment models for future benefit years.

CMS also proposes, beginning with the 2023 benefit year, to collect and extract from issuers’ EDGE servers a new data element, a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) indicator, and to extract plan ID and rating area data elements issuers have submitted to their EDGE servers from certain benefit years prior to the 2021 benefit year. We also propose a risk adjustment user fee for the 2024 benefit year of $0.21 per member per month.

Finally, we propose to repeal the ability of all states, including those prior participant states that had previously submitted a state flexibility request, to request a reduction in risk adjustment state transfers starting with the 2025 benefit year. We also solicit comments on the requests submitted by Alabama to reduce risk adjustment state transfers by 50% in its individual (including catastrophic and non-catastrophic risk pools) and small group markets for the 2024 benefit year.

HHS Risk Adjustment Data Validation

CMS proposes further refinements to HHS Risk Adjustment Data Validation (HHS-RADV) to promote the goals of HHS-RADV and support the timely release of HHS-RADV results. Beginning with the 2021 benefit year, CMS proposes to no longer exempt exiting issuers from adjustments to risk scores and risk adjustment transfers when they are negative error rate outliers in the applicable benefit year’s HHS-RADV results. Additionally, CMS proposes to change the materiality threshold for random and targeted sampling from $15 million in total annual premiums Statewide to 30,000 total billable member months Statewide. CMS proposes to shorten the window to confirm or dispute the findings of the Second Validation Audit to within 15 calendar days of the notification by HHS beginning with the 2022 benefit year. Finally, we solicit comments on discontinuing the use of the lifelong permanent condition list and the use of Non-EDGE Claims in HHS-RADV. 

Premium Adjustment Percentage and Payment Parameters

With the release of the proposed rule, CMS is issuing the 2024 benefit year premium adjustment percentage, the maximum annual limitation on cost sharing, reduced maximum annual limitation on cost sharing, and the required contribution percentage (payment parameters) in guidance by January 2023, consistent with policy finalized in the 2022 Payment Notice.

Bolstering Program Integrity

Establish Improper Payment Pre-Testing and Assessment for State Marketplaces

To comply with the Payment Integrity Information Act of 2019 (PIIA), CMS proposes to establish and implement a required Improper Payment Pre-Testing and Assessment (IPPTA) program in calendar years 2024 – 2025. The proposed IPPTA would prepare State Marketplaces for the planned measurement of improper payments of APTC by testing processes and procedures that support HHS’s review of determinations of APTC. IPPTA would also provide a mechanism for HHS and State Marketplaces to share information that would aid in developing a measurement process in future years.

New Requirements Related to Agents, Brokers, or Web-brokers

CMS proposes to allow HHS additional time to review evidence submitted by agents, brokers, or web-brokers to rebut allegations that led to suspension of their Marketplace agreements or to request reconsideration of termination of their Marketplace agreements. For suspensions, HHS would receive an additional 15 calendar days, or a total of up to 45 calendar days, to review evidence and notify the submitting agents, brokers, or web-brokers of HHS’ determination regarding the suspension of their Marketplace agreements. For terminations, HHS would receive an additional 30 calendar days, or a total of up to 60 calendar days to review reconsideration requests and notify the submitting agents, brokers, or web-brokers of HHS’ reconsideration decision related to the termination of their Marketplace agreements. These additional days are needed as the review process can involve parsing complex technical information and data, revisiting consumer complaints, and reaching out to consumers individually.

CMS also proposes to require agents, brokers, and web-brokers to document that eligibility application information has been reviewed by and confirmed to be accurate by the consumer prior to application submission. This proposal would help with enforcement activities related to agents, brokers, and web-brokers and help expedite the adjudication of consumer complaints related to the provision of incorrect information of their eligibility applications. We are proposing that this documentation be retained by the agent, broker, or web-broker for a minimum 10 years and be produced upon request in response to monitoring, audit, and enforcement activities.

In addition, CMS proposes to require agents, brokers, or web-brokers to document the receipt of consent from the consumers they are assisting. This proposal would help with enforcement and help resolve disputes between enrolling entities and consumers, or between multiple enrolling entities. We are proposing that this documentation be retained by the agent, broker, or web-broker for a minimum of 10 years and be produced upon request in response to monitoring, audit, and enforcement activities.

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense

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“The Biden-Harris Administration is committed to expanding access to vital prevention and treatment services,” said HHS Secretary Xavier Becerra.  “Providing whole person support and services through Medicare will improve health and wellbeing for millions of Americans and even save lives.” 

“Access to services promoting behavioral health, wellness, and whole-person care is key to helping people achieve the best health possible,” said CMS Administrator Chiquita Brooks-LaSure. “The Physician Fee Schedule final rule ensures that the people we serve will experience coordinated care and that they have access to prevention and treatment services for substance use, mental health services, crisis intervention, and pain care.”

“Together, we are building a stronger Medicare program,” said Deputy Administrator and Director for the Center for Medicare, Dr. Meena Seshamani. “No matter who you are, or what diagnoses you have, these changes will help ensure that Medicare treats the whole person— caring for physical health, behavioral health, and social needs that are integral to health— and ensuring access to the high-quality care all people deserve.”

Coverage for Behavioral Health Services and Opioid Use Disorder Treatment

In line with the 2022 CMS Behavioral Health Strategy, CMS is strengthening access to vital behavioral health services. CMS is making it easier for Medicare beneficiaries to get behavioral health services, by allowing behavioral health clinicians like licensed professional counselors and marriage and family therapists to offer services under general (rather than direct) supervision of the Medicare practitioner. Medicare will pay Opioid Treatment Programs that use telecommunications with patients to initiate treatment with buprenorphine. CMS is also clarifying that Opioid Treatment Programs can bill for opioid use disorder treatment services provided through mobile units, such as vans, in accordance with Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) guidance.  These policies may increase access in rural and other underserved areas.

CMS is also finalizing policies to pay for clinical psychologists and licensed clinical social workers to furnish integrated behavioral health care as part of a primary care team. Finally, Medicare will provide a new monthly payment for comprehensive treatment and management services for patients with chronic pain. These new services offer a whole-person approach to care.

Expanding and Enhancing Accountable Care
CMS is finalizing changes to the Medicare Shared Savings Program, the nation’s largest Accountable Care Organization program, covering more than 11 million people with Medicare and including more than 500,000 health care providers. These policies represent some of the most significant reforms since the program was established in 2011, and the first Accountable Care Organizations (ACOs), which are groups of health care providers who come together to give coordinated, high-quality care to people with Medicare, began participating in 2012. Through these policies, which are central to the Medicare Value-Based Care Strategy, CMS will take important steps toward our 2030 goal of having 100% of Traditional Medicare beneficiaries in an accountable care relationship with their healthcare provider by 2030. CMS is finalizing proposals to incorporate advance shared savings payments to certain new ACOs that can be used to support their participation in the Shared Savings Program, including hiring additional staff or addressing social needs of people with Medicare. CMS is also finalizing a health equity adjustment to an ACO’s quality score, revising the benchmarking methodology, and allowing longer periods of time for ACOs to become accustomed to accountable care before being liable for downside risk, all of which are expected to increase participation in rural and underserved areas.

Reducing Barriers and Expanding Coverage for Colon Cancer Screening

Colon and rectal cancers continue to be a leading cause of death in the United States with even higher new cases and death rates for Black Americans, American Indians, and Alaska Natives. Medicare will now reduce the minimum age for colorectal cancer screening from 50 to 45 years, in alignment with recently revised policy recommendations by the U.S. Preventive Services Task Force. Additionally, Medicare will now cover as a preventive service a follow-on screening colonoscopy after a non-invasive stool-based test returns a positive result, which means that beneficiaries will not have out-of-pocket costs for both tests.

Finalizing Payment for Dental Services that are Integral to Covered Medical Services

CMS is codifying current policies in which Medicare Parts A and B pay for dental services when that service is integral to treating a beneficiary’s medical condition. Medicare will also pay for dental examinations and treatments in more circumstances, such as to eliminate infection preceding an organ transplant and certain cardiac procedures beginning in CY 2023 and prior to treatment for head and neck cancers beginning in CY 2024. Finally, CMS is establishing an annual process to review public input on other circumstances when payment for dental services may be allowed.

Payment Rates for CY 2023

The CY 2023 PFS conversion factor is $33.06, a decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61. This conversion factor reflects the statutorily required update of 0% for CY 2023, expiration of the temporary 3% supplemental increase in PFS payments for CY 2022 provided by the Protecting Medicare and American Farmers From Sequester Cuts Act, and the statutorily required budget neutrality adjustment to account for changes in payment rates.

For a fact sheet on the CY 2023 Physician Fee Schedule Final Rule, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule

For a fact sheet on final changes to the CY 2023 Quality Payment Program, please visit: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2136/2023%20Quality%20Payment%20Program%20Final%20Rule%20Resources.zip

For a fact sheet on final changes to the Medicare Shared Savings Program, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program

For a CMS blog on behavioral health polices, please visit: https://www.cms.gov/blog/strengthening-behavioral-health-care-people-medicare-0?check_logged_in=1

To view the CY 2023 Physician Fee Schedule and Quality Payment Program final rule, please visit: https://www.federalregister.gov/public-inspection/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other

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Secretary Xavier Becerra: “Today’s action marks a critical step toward reducing health care costs for American families and increasing competition. We’re moving full-speed ahead on Inflation Reduction Act implementation to deliver results for millions of Americans.” 

CMS Administrator Chiquita Brooks-LaSure: “CMS is swiftly implementing the historic Inflation Reduction Act to make the new law and the benefits it provides a reality for the people we serve. The temporary Medicare Part B payment increase for qualifying biosimilars that is now in effect will foster competition in the drug marketplace for conditions such as diabetes, cancer, and immune disorders, and will improve access to these life-saving medicines that help keep people with Medicare healthy.” 

Additional Background: 

According to the United States Food & Drug Administration (FDA), biosimilars are a diverse category of products and are generally large, complex molecules. Biological products may be produced through biotechnology in a living system, such as a microorganism, plant cell, or animal cell, and represent the fastest growing segment of the pharmaceutical industry. 

In accordance with section 11403 of the Inflation Reduction Act, CMS is implementing a temporary increase in payment under Medicare for qualifying biosimilars. The new law provides for a temporary increase in the add-on payment for qualifying biosimilars whose average sales price (ASP) is not more than the price of the associated reference biological product. This provision encourages the creation and utilization of biosimilars to compete with original biologic products and incentivizes innovation for less costly access to these important therapies in the United States. 

By statute, Medicare Part B generally pays 106% of ASP (ASP plus 6%) for separately payable drugs and biologicals furnished in physician offices, hospital outpatient departments, and ambulatory surgical centers, with some exceptions. ASP is calculated based on manufacturers’ sales to all U.S. purchasers minus manufacturer rebates, discounts, and price concessions (with certain exceptions). Manufacturers report ASP data to CMS quarterly. 

Prior to the implementation of the provisions in section 11403 of the Inflation Reduction Act, CMS paid biosimilars a rate of the biosimilar’s ASP plus an add-on of 6% of the reference biological product’s ASP. Under section 11403 of the Inflation Reduction Act, qualifying biosimilars will temporarily be paid ASP plus 8% (rather than plus 6%) of the reference biological product’s ASP for a 5-year period. For existing qualifying biosimilars for which payment was made using ASP as of September 30, 2022, the 5-year period begins on October 1, 2022. For new qualifying biosimilars for which payment is first made using ASP between October 1, 2022, and December 31, 2027, the applicable 5-year period begins on the first day of the calendar quarter during which such payment is made.

The goal of the temporary add-on payment for providers is to increase access to biosimilars, as well as to encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.

CMS has posted the quarterly Medicare Part B drug pricing file that reflects the temporary increased amount for qualifying biosimilar biological products. The October 2022 Medicare Part B quarterly drug pricing file can be accessed at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice.

Public payment files for biosimilars in the hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) can be found at the following links: 

• HOPD:  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates
• ASC: https://www.cms.gov/medicare/medicare-fee-for-service-payment/ascpayment/11_addenda_updates

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“Since the Supreme Court’s decision in Dobbs, we have seen the gut-wrenching stories of women suffering and not getting the care they need because of newly-enacted laws that restrict abortion care. We have also seen state legislatures try to mislead women by saying they’re protecting patients while also making it a crime to provide abortion care.  At my request and at President Biden’s direction, HHS has been and will continue to take concrete action, like today’s invitation to states, that will protect women’s access to reproductive care, including abortion,” said HHS Secretary Becerra.

“With today’s guidance, we encourage states interested in developing approaches that use federal funding, including Medicaid funding under section 1115 demonstration authority, to engage with us to expand access to care. States interested in federal Medicaid funding to expand access to care within the scope of Medicaid’s legal authority for women traveling from a state that has restricted or prohibited abortion are encouraged to engage with the Centers for Medicare & Medicaid Services,” said CMS Administrator Brooks-LaSure.

The letter comes just days after a Federal court granted a preliminary injunction restraining and enjoining the State of Idaho from enforcing Idaho’s anti-abortion law in situations where an abortion is a necessary stabilizing treatment for an emergency medical condition.  Earlier this month, the U.S. government filed a lawsuit alleging that Idaho’s anti-abortion law, which went into effect this week, directly conflicts with the federal Emergency Medical Treatment and Labor Act (EMTALA) in those situations. Last month, HHS issued guidance affirming EMTALA’s requirements, and Secretary Becerra sent a letter – PDF to providers reminding them of their obligations to provide access to abortion in emergency situations.

Read today’s letter to governors in full – PDF.*

HHS also released a report today that the agency prepared for the President on HHS actions taken to-date to ensure access to reproductive health care following the Supreme Court’s ruling, with further details on future actions and commitments. You can read the report, “Secretary’s Report: Health Care Under Attack: An Action Plan to Protect and Strengthen Reproductive Care,” here. A summary of actions included in the Secretary’s message from the report is below:

Protecting Emergency Medical Care:  HHS issued guidance – PDF and a letter from Secretary Becerra – PDF to reaffirm that the Emergency Medical Treatment and Active Labor Act (EMTALA, also known as the Emergency Medical Treatment and Labor Act) protects providers when offering legally-mandated, life- or health-saving abortion services as stabilizing care for emergency medical conditions.

Safeguarding Information on Health and Rights for Patients and Providers:  HHS launched the ReproductiveRights.gov public awareness website, which includes accurate information about reproductive health, including a Know-Your-Rights patient fact sheet to help patients and providers.

Protecting Patients and Providers from Discrimination:

• HHS issued a proposed rule that would strengthen the regulations interpreting the nondiscrimination provision of the Affordable Care Act (ACA) and would reinforce that discrimination on the basis of sex includes discrimination on the basis of pregnancy or related conditions.
• HHS issued guidance to roughly 60,000 U.S. retail pharmacies, clarifying their obligations under federal civil rights laws.

Protecting Patient Privacy: HHS issued guidance that clarifies to patients and providers the extent to which federal law and regulations protect individuals’ private medical information when seeking abortion and other forms of reproductive health care, as well as when using apps on smartphones.

Supporting Quality Reproductive Health Care: HHS announced nearly $3 million in new funding to bolster training and technical assistance for the nationwide network of Title X family planning providers.

Protecting Access to Birth Control: 

• With the Departments of the Treasury and Labor, we convened a meeting with health insurers and sent them a letter, calling on the industry to commit to meeting their obligations to provide contraceptives as required by the ACA.
• Later, in response to this conversation, we issued guidance to clarify protections for birth control coverage under the ACA. Under the ACA, most private health plans are required to provide birth control and family planning counseling at no additional cost.

*This content is in the process of Section 508 review. If you need immediate assistance accessing this content, please submit a request to digital@hhs.gov. Content will be updated pending the outcome of the Section 508 review.

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“The Biden-Harris Administration is deeply committed to ensuring everyone is able to get the high-quality care they need – within the comfort of their own home or community,” said HHS Secretary Xavier Becerra. “Today we are expanding access to home and community-based services so even more states and territories are equipped to best serve the millions of seniors and people with disabilities across the country.”

“We’re putting the full weight of this agency behind solutions that can meet people where they are and help get them to where they want to be when it comes to health care,” said CMS Administrator Chiquita Brooks-LaSure. “Money Follows the Person has a proven track record of helping seniors and people with disabilities transition safely from institutional care to their own homes and communities. Letting ‘money follow the person’ is key to those successes, and to the Biden-Harris Administration’s commitment to affordable, accessible, person-centered care.”

Awards of up to $5 million are being announced for Illinois, Kansas, and New Hampshire, as well as for American Samoa and Puerto Rico – the first time MFP grants have been made available to territories. These awards will support the early planning phase for their MFP programs. This includes: 

• Establishing partnerships with community stakeholders, including those representing diverse and underserved populations, Tribal entities and governments, key state and local agencies (such as state and local public housing authorities), and community-based organizations;
• Conducting system assessments to better understand how HCBS support local residents;
• Developing community transition programs;
• Establishing or enhancing Medicaid HCBS quality improvement programs; and
• Recruiting HCBS providers as well as expert providers for transition coordination and technical assistance.

A new report from CMS also describes how MFP has helped facilitate more than 107,000 transitions out of institutional settings since 2008. It also indicates that, thanks in part to programs like MFP, more than 85% of people who used Medicaid long-term services and supports in 2019 received HCBS rather than institutional services. First authorized in 2006, MFP has provided states with more than $4 billion to support people who choose to transition out of institutions and back into their homes and communities.

Supporting HCBS is a critical part of the Biden-Harris Administration’s commitment to helping older adults and individuals with disabilities live safely and independently in their homes and communities. Medicaid is the primary funder of HCBS nationally, and plays a critical role in supporting states’ efforts to strengthen these services for their beneficiaries. Through the American Rescue Plan, President Biden temporarily increased Medicaid funding for HCBS, and every state elected to participate in this program has submitted a detailed plan for how they will use these funds. The administration estimates that this change will ultimately result in $25 billion in increased funding, allowing states to develop innovative ways to address existing HCBS workforce and structural issues, expand the capacity of critical services, and begin to meet the needs of people with disabilities, family caregivers, and providers. In June 2022, HHS notified states that they now have an additional year – through March 31, 2025 – to use this critical funding made available by the American Rescue Plan.

For more information on MFP, visit Medicaid.gov.

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Awards to 36 grantees support President Biden’s Executive Orders on Strengthening Medicaid and the Affordable Care Act, and represent the largest outreach and enrollment investment ever made through Connecting Kids to Coverage program.

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), awarded $49 million to organizations on the frontlines of reducing uninsured rates and connecting more children, parents, and families to health care coverage. In support of President Biden’s Executive Orders on Strengthening Medicaid and the Affordable Care Act, and HHS Secretary Xavier Becerra’s priority of expanding access to affordable, quality health care, these awards represent the largest investment CMS has ever made in outreach and enrollment through the Connecting Kids to Coverage program. 

“At HHS, it is a top priority to make high-quality health care accessible and affordable for every American,” said HHS Secretary Xavier Becerra. “This past year, through unprecedented investments in outreach and enrollment efforts, a record-breaking 14.5 million people signed up for health care coverage through the ACA Marketplace. With today’s historic investment for children and parents, we will redouble our efforts to get families covered — and give them the peace of mind that comes with it.” 

Grantees will provide enrollment and renewal assistance to children and their families, and — for the first time ever — to expectant parents to promote improved maternal and infant health outcomes. CMS issued 36 cooperative agreements in 20 states through Medicaid’s Connecting Kids to Coverage program. Grantees — including state and local governments, tribal organizations, federal health safety net organizations, non-profits, and schools — will each receive up to $1.5 million over three years to advance Medicaid and Children’s Health Insurance Program (CHIP) enrollment and retention. 

“Ensuring kids and families have health coverage is a key priority for the Biden-Harris Administration. CMS is committed to using all available tools to expand coverage,” said CMS Administrator Chiquita Brooks-LaSure. “Families often seek help and information from community organizations they know and trust, and we recognize the pivotal role they play in advancing Medicaid and Children’s Health Insurance Program enrollment and retention.”

Grantees will participate in the Connecting Kids to Coverage National Campaign efforts, including the national back-to-school initiative, the year-round enrollment initiative, and new initiatives focused on retaining individuals in Medicaid and CHIP. This work will be key, not only as states prepare to resume normal Medicaid and CHIP operations once the COVID-19 public health emergency ends, but also as CMS continues to build on the Biden-Harris Administration’s success connecting record-breaking numbers of people to health care coverage.” 

Additionally, grantees will work on several unique activities of their own. They may:

• Engage schools and other programs serving young people.
• Bridge demographic health disparities by targeting communities with low coverage.
• Establish and develop application assistance resources to provide high-quality, reliable Medicaid/CHIP enrollment and renewal services in local communities.
• Use social media to conduct virtual outreach and enrollment assistance.
• Use parent mentors and community health workers to assist families with enrolling in Medicaid and CHIP, retaining coverage, and addressing social determinants of health.

This unprecedented funding bridges many of the gaps that prevent eligible children from connecting to coverage. Of America’s 4 million uninsured children, studies show that 2.3 million are eligible for Medicaid and CHIP. However, many of their families either do not know they are eligible or struggle with enrollment. There are also pronounced disparities. American Indian and Alaska Native children have the highest uninsured rates (11.8%), followed by those who are Hispanic (11.4%) and non-Hispanic Black (5.9%). Targeting new and expectant parents can also lead to increased child enrollment, since infants born to people on Medicaid and CHIP are automatically deemed eligible for one year. 

The new Connecting Kids to Coverage grantees were funded through the Helping Ensure Access for Little Ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable Act of 2017 (HEALTHY KIDS Act). The HEALTHY KIDS Act provides continued funding for outreach and enrollment to reduce the number of children eligible for, but not enrolled in, Medicaid and CHIP. Since 2009, the HEALTHY KIDS Act has helped CMS award $265 million to more than 330 community-based organizations, states, and local governments. 

For a complete list of the grantees and more information, visit insurekidsnow.gov.

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The U.S. Department of Health and Human Services (HHS) announced approval of Colorado’s Section 1332 State Innovation Waiver amendment request to create the “Colorado Option,” a state-specific health coverage plan that increases health coverage enrollment and lowers health care costs, making insurance more affordable and accessible for nearly 10,000 Coloradans starting in 2023. It is designed to reduce racial and ethnic health disparities by providing new coverage options for Coloradans, reflecting the Biden-Harris Administration’s commitment to advancing health equity. 

“We are thrilled to partner with Colorado in our shared commitment to lowering health care costs and ensuring greater access to quality, affordable care,” said HHS Secretary Xavier Becerra. “The Colorado Option will help thousands more families sign up for health coverage. I applaud Governor Jared Polis and encourage all states to pursue innovative ways to ensure health care is within reach for their residents.”

Section 1332 of the Affordable Care Act (ACA) allows states to apply for State Innovation Waivers to pursue innovative strategies for providing residents with access to high-quality, affordable coverage. Colorado is the first in the nation to adopt this waiver to introduce a new and more affordable state-based health insurance option, and leverage federal savings to support state subsidies to improve affordability and coverage initiatives. Colorado projects that approximately 32,000 Coloradans will gain health insurance under the amended waiver by 2027, which would be an increase of approximately 15% in the individual market.

This 1332 waiver amendment implements the Colorado Option, which lowers premiums and health care costs while making it easier for consumers to compare their coverage options and select the best plan that fits their needs. Starting in 2023, the Colorado Option will be available to all Coloradans who enroll in health insurance plans on the individual market (i.e., not through an employer) and small employers with less than 100 employees. Colorado Option plans will lower health insurance premiums for individuals, families, and small businesses by up to 15% by 2025.

The Colorado Option will operate in tandem with Colorado’s existing section 1332 waiver, a state-based reinsurance program, which is authorized to continue under the amended waiver. The amended waiver is expected to lower premiums by an average of approximately $132 per person per month (or 22%). This is even further than the state’s reinsurance waiver program alone, which has already resulted in statewide average premium reductions of approximately 20% since its implementation in 2020.

“Through this new model, Colorado leverages federal savings to expand affordability and coverage in the state like no other state has done before. The Colorado Option is groundbreaking and a step in the right direction to reduce the uninsured rate, while investing in health insurance coverage affordability and improvements, and advancing health equity,” said CMS Administrator Chiquita Brooks-LaSure. “We encourage all states to consider innovative ways to use section 1332 waivers in the future to expand and improve coverage and lower costs for their residents.”

The Colorado Option will cover all essential health benefits required by the ACA, including many high value services, like primary care, behavioral health, and prenatal visits, at no cost. It will combine standard health benefit plans, required premium reductions, and increased state subsidies for those currently eligible and those not currently eligible for federal subsidies under the ACA to make coverage more affordable. The state’s waiver plan increases competition by establishing premium reduction targets for the Colorado Option and implements better regulatory and programmatic mechanisms as a backstop to ensure providers, hospitals, and issuers meet those targets.

In doing so, the amended waiver will generate savings that the federal government will pass on to the state to implement their waiver (referred to as federal “pass-through funding”). The state will use these savings to implement the amended waiver and make coverage more affordable; this will include providing state-based subsidies through a state program to enhance the financial help available to Coloradans enrolling in coverage, ultimately increasing access to care in the state. As a result, individual market consumers are expected to continue seeing lower premiums, which should attract new consumers while also keeping current consumers enrolled in coverage.

Find more information about the Colorado Option here: Colorado Option website. 

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