Dayspring Health Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, Dec. 25 -- Geogy Thomas, CEO of Dayspring Health, Jellico, Tennessee, has issued a public comment on the Centers for Medicare and Medicaid Services proposed rule entitled "Patient Protection and Affordable Care Act: HHS Notice of Benefit and Payment Parameters for 2022 and Pharmacy Benefit Manager Standards". The comment was written and posted on Dec. 23, 2020:

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Dayspring Health is pleased to submit the following comments in response to CMS-9914-P, the Notice of Benefit and Payment Parameters (NBPP) for 2022. NACHC is the national membership organization for federally qualified health centers (referred to as "health centers" or "FQHCs") throughout the country. Health centers are non-profit, community-directed providers that serve as the primary health home to over 28 million people, or 1 in 12 Americans.

The majority of health center patients live below the federal poverty level (FPL) and face multiple social and environmental factors that affect their need for health care, their ability to access care and their ability to maintain coverage. Through over 11,000 sites across the country, FQHCs provide affordable, high quality, comprehensive primary care services to these individuals, regardless of their insurance status or ability to pay for services. For additional information on Dayspring Health's mission and the Health Center Program, visit www.dayspringhealth.org

Since the passage of the Patient Protection and Affordable Care Act (ACA), health centers have played a critical role in the success of the health insurance Marketplaces in every state.

Health centers serve as the health home for millions of Americans who are eligible for reduced-cost coverage through the Marketplaces. Additionally, health centers have continued to serve as a key source of outreach and enrollment assistance nationally. In 2017 alone, health centers assisted over five million people in their efforts to gain health care coverage through Medicaid, CHIP, Medicare, or the Marketplace./1

Health center enrollment assistance personnel have also helped individuals with re-enrollments/renewals, hardship exemptions and understanding of how to utilize their newly-acquired insurance appropriately.

Given the long-term, demonstrated commitment by health centers to help individuals gain access to affordable care and coverage, we request that the rule be withdrawn and be reconsidered in a manner that provides stronger opportunities for the health center program to support those impacted by the NBPP. Our aim in offering these comments is to ensure that communities continue to have access to affordable and comprehensive health care.

WHO WE ARE

Dayspring Health is a federally qualified health center with 4 medical and dental clinics in East TN and South KY. We have proudly served the people of Appalachia for more than 40 years without regard to their insurance status or ability to pay. Today, we provide medical, prenatal, dental and behavioral health care to over 10,000 people of all ages. Because of the trust we have earned with patients, Dayspring Health has become a safety net provider of primary care in this region. We write as advocates for the patients, neighborhoods we serve, and the rural poor.

THE BASES FOR OUR CONCERNS

Dayspring Health opposes CMS's efforts to privatize healthcare enrollment and encourages the agency to continue to invest in marketplaces that increase consumers' access to affordable and comprehensive health care coverage.

The proposed rule would encourage Navigators and Certified Application Counselors to use enhanced direct enrollment entities. See 155.220(c)(3)(iii)(A). In doing so, this additional form of privatization of HealthCare.gov functions and related transition to direct enrollment pathways has the potential to create consumer confusion and lead to gaps in coverage or dropped coverage altogether. Brokers may be less likely to refer people to plans that do not pay commissions or assist consumers with determining their Medicaid eligibility. The broker-centric model could also increase pressure for consumers to enroll in short-term, limited-duration (STLD) and other less comprehensive, non-ACA compliant plans.

On November 1, 2020, CMS approved Georgia's Section 1332 waiver, endorsing a dramatic departure from the plan shopping and enrollment experience currently available to people nationwide through either HealthCare.gov or a state-based marketplace. Once implemented, Georgia's approved waiver will end their participation in HealthCare.gov through which half a million Georgians currently enroll; instead, enrollment functions will be privatized and consumers will only be able to shop only through agents and web-based brokers. This waiver will lead to lower enrollment in comprehensive coverage.

Dayspring Health is especially concerned that any increased privatization of HealthCare.gov could significantly harm the patient populations that community health centers are intended to serve. These patients are generally unable to afford private insurance. Privatization of HealthCare.gov would likely make cheaper, less comprehensive coverage such as STLD plans attractive to health center patients. In turn, these less comprehensive plans will force community health centers, which already are federally mandated to serve every patient regardless of ability to pay, to absorb the costs of care that is not covered by these plans.

Dayspring Health strongly encourages CMS to maintain the 1332 waiver statutory guardrails to prevent states from eliminating significant Affordable Care Act protections.

The 1332 waiver's statutory guardrails require that waivers cover at least as many people, with coverage at least as comprehensive and affordable as would be the case without the waiver, without increasing the federal deficit. 1332 waivers were designed to help states tailor their marketplace to meet the specific coverage needs of its residents.

This includes incentives such as funding for Navigator programs that conduct outreach and enrollment assistance activities, and flexibilities in marketplace design granted through waivers of certain requirements.

As it relates to health centers, Dayspring Health that CMS closely monitor waiver proposals to ensure fair and adequate access and payment for FQHC services. Specifically, the FQHC protections in Section 1311(c)(1)(C) ) of the Affordable Care Act (ACA) and Section 10104(b)(2) of the ACA ( adding (g) to Section 1311 of the ACA)) should not be compromised in any waiver granted to a state under Section 1332. Dayspring Health encourages CMS to prioritize 1332 waiver proposals that maintain the statutory requirement for qualified health plans to include essential community providers, like FQHCs, that serve predominately low-income individuals and honor the FQHC prospective payment system (PPS). CMS should not finalize this proposed rule that essentially encourages states to submit waiver proposals that would weaken protections for people with pre-existing conditions, cuts to financial assistance for consumers with low incomes and increases out of pocket costs. In the interest of strengthen federal and state marketplaces, CMS should encourage states to work with health centers to explore 1332 waivers that expand the vital enabling services, including outreach and enrollment assistance, that over 1,400 health centers provide to improve the consumer experience and access to care.

In addition to meeting the criteria set forth in the statutory "guardrails," Section 1332 waiver proposals are required to undergo a process that ensures meaningful public input as well as periodic evaluation. This proposed rule would allow states to make fundamental changes without even going through the waiver process. This would deprive consumers of a public comment period before such a change is made. Removing the requirements for public notice threatens the ability for providers to learn of proposed changes and provide valuable public comment in a timely manner. Dayspring Health strongly supports adequate notification that offers the opportunity for stakeholders to provide public comment on the implications - both positive and negative - of regulatory changes pursued through Section 1332 authority.

Dayspring Health strongly opposes cuts to federal and state-based marketplace user fees and requests that CMS instead increase user fees to restore outreach and enrollment assistance programs. The proposed rule would cut the federal marketplace user fee by 25 percent, from 3 percent to 2.25 percent and would cut the user fee for state-based marketplaces that use the federal platform from 2.5 percent to 1.75 percent. See 156.50. Dayspring Health opposes this provision.

The marketplace user fee ― a fixed percentage of premium revenue paid by insurers ― supports crical funcons, including the operation and improvement of the HealthCare.gov website, the Marketplace call center, the Navigator program, consumer outreach, and advertising. The HealthCare.gov website, the Marketplace call center, and these consumer-facing functions are critical for health centers across the country because a robust option for consumers encourages better patient outcomes by improving customer service and increasing enrollment.

The proposed rule's rationale for the cut is that the lower user fee would be sufficient to fund current marketplace activities. However, current activities are inadequate. CMS has virtually ceased marketing and outreach and has slashed funding for Navigators in FFM states, which received an 84% reduction in funding (from $63 million to $10 million) between 2016 and 2020.1 Health Centers have utilized marketing and outreach funding under the ACA by incorporating Community Health Workers into their patient care teams. Community Health Workers and Enrollment assisters are public health workers who are trusted members of (or are closely connected to) a community. They provide unbiased enrollment assistance and facilitate access to services which improve the quality of care for patients. Unlike Community Health Workers and enrollment assisters funded by the higher user fees, private navigators and assisters likely will be paid commissions by a third party.

The third-party payor creates an interest in navigators and assisters to direct consumers to certain private products, rather than promoting consumer utilization in a neutral manner. Given that these core marketplace functions were funded by user fees, the impact of CMS's changes is that patients will have greater difficulty finding information about their eligibility for Medicaid and related programs associated with HealthCare.gov.

Rather than cutting the user fee, it should be increased to 3.5 percent (the level in effect prior to 2020) to restore outreach and enrollment assistance programs and to fund continued improvements to HealthCare.gov, including technological enhancements and improved customer service. In particular, the restored outreach capabilities would assist Health Centers in employing Navigators which are neutral because are compensated by their employer on a non-commission basis. The restored enrollment assistance programs would reduce burden on the safety net and generally ensure better public health, as Americans tend to be more healthy when they can receive primary care.

OUR ASK

Dayspring Health urges CMS to reverse changes that have resulted in increased costs to consumers or decreased the amount or availability of Advanced Premium Tax Credits (APTCs) or related cost-sharing reductions.

The proposed rule continues the Administration's 2019 change in the formula used to calculate premium tax credits, which cut financial assistance for millions of people. See 156.130(e). If continued, the formula change will have an even greater impact in 2022, raising premiums by an estimated 4.7 percent for most subsidized marketplace consumers after accounting for their tax credits (compared to about 2.7 percent this year). That amounts to a $360 annual premium increase for a family of four with $80,000 in income.

The same formula change also increases the limit on consumers' total out-of-pocket expenses, which applies to both marketplace and employer plans. In 2022, that limit will be $400 higher for an individual, and $800 higher for families, than if the 2019 change were reversed.

In 2019, 91% of patients live at or below 200% of the Federal Poverty Line (FPL)./1

Nearly 68% of health center patients live at or below 100% of the FPL, At this FPL, these individuals are not eligible for subsidies to purchase coverage in the ACA Marketplaces and unless a state expands its Medicaid program, these patients fall into a coverage gap. For the remainder of the health center patients - that fall between 101-200% of the FPL and above 200% of the FPL, these consumers are frequently eligible for Marketplace coverage, including Advanced Premium Tax Credits (APTCs) and cost-sharing reductions. [YOUR ORGANIZATION] is concerned that any increases in premiums and cost-sharing burdens could make coverage cost-prohibitive for our low-income patients. For many of these individuals, the slightest increase in costs could lead to individuals and families foregoing coverage altogether.

We appreciate the opportunity to provide comment on this proposed rule. Should you have any questions about our comments, please feel free to contact me at [email protected]

Sincerely,

Geogy Thomas, MD, FAAFP, MBA

Chief Executive Officer

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1/ [Footnote not provided in original]

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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0151-0005

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