Health Equity blog

On October 4, the Centers for Medicare and Medicaid Services (CMS) issued its proposed Notice of Benefit and Payment Parameters for the 2026 plan year (published in the Federal Register on October 10) that would implement standards for plans operating in the health insurance Marketplace established by the Affordable Care Act (ACA). The proposed rule includes requiring carriers to set premium payment thresholds to help reduce enrollee coverage terminations, which particularly creates risk for lower income populations who often fail to timely pay smaller premium amounts. Another facet of the rule aimed at increasing health equity is more active federal monitoring of certain Marketplace plans to ensure their provider networks include a sufficient number and geographic distribution of Essential Community Providers (ECPs), who commonly serve people with traditionally unmet medical needs and/or are low-income. Comments on the proposed rule will be accepted through November 12, 2024.

As part of Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements, nearly half the nation’s children are entitled to receive a comprehensive range of preventative, diagnostic, and treatment services, including mental health care, well-child visits, and dental, vision and hearing services. CMS’s guidance, issued on September 26, outlines strategies and best practices for states in implementing the EPSDT requirements. Ensuring that eligible children receive these health care services is vital to improving their long-term health care outcomes.

CMS’s new Expanding Access to Women’s Health program seeks to solidify women’s health coverage and ensure access to critical health benefits in 14 states (AR, CO, HI, MA, ME, MS, NE, NH, NJ, NM, PA, VT, WA, and WI) and D.C. Recipients can use these funds to develop activities and foster educational campaigns to address historical disparities in access to reproductive and maternal health care. Improving and broadening women’s health care and coverage are critical to reducing maternal mortality rates and improving women’s overall well-being.

On October 7, the Supreme Court of the United States (SCOTUS) released a long list of cases for which it was either granting or denying a petitioner’s request for certiorari. Among the denials was a petition from the Department of Health and Human Services (HHS), seeking the Court’s review of a 5th Circuit decision that Emergency Medical Treatment and Active Labor Act’s (EMTALA’s) federal requirements with regard to when a pregnant individual’s life is in danger or is at serious risk of harm do not conflict with Texas state law that severely restricts access to abortions. The case began as a challenge by Texas and two medical groups to HHS guidance, which advised hospitals that EMTALA may require hospitals to provide abortions as stabilizing treatment, despite situations in which state law would otherwise prohibit the abortion. The 5th Circuit disagreed with HHS’s guidance, thus prohibiting its enforcement against Texas.

California leads the way once again in spearheading efforts to improve health equity and outcomes for its population. Early last year, Medi-Cal received federal approval for its Justice-Involved Reentry Initiative (JIRI) which offers targeted services to address some of the most critical health care needs of Medi-Cal eligible individuals returning to their communities after incarceration. Among these services will be mental health and substance use disorder (SUD)-related care that will begin 90 days prior to an individual’s release from custody. Effective October 1, 2024, the initial rollout of JIRI services will be available in 3 counties (Inyo, Santa Clara, and Yuba), but will expand to every California county by October 1, 2026. Given that a disproportionate percentage of the state’s incarcerated population is comprised of racial and ethnic minorities, this program will have a particular impact on individuals who are most at risk for their health care needs not being adequately addressed post-release.

Earlier this month, the Drug Enforcement Agency (DEA) submitted to the Office of Management and Budget (OMB) for approval its proposed final rule for extending virtual prescribing practices. The proposed rule is not yet publicly available, and remains subject to OMB clearance, but this action indicates it is expected soon. Without this extension, telemedicine prescribing of controlled substances absent a prior in-person consultation with the patient’s provider would be prohibited come January 1, 2025. During the COVID-19 pandemic, telemedicine consultations became critical to ensuring vitally needed medications were accessible by some of the most critically ill and vulnerable populations.

On September 9, the Department of Health and Human Services (HHS), Department of Labor (DOL), and the Treasury Department released new final rules implementing the Mental Health Parity and Addiction Equity Act (MHPAEA). As the country continues to struggle with an escalating mental health and substance use disorder (SUD) crisis, MHPAEA has failed since its enactment nearly 16 years ago to reduce barriers that individuals encounter in trying to access critically needed mental health resources through their health plans. In fact, disparities have not only persisted, but they have also actually grown. One of the hallmarks of the new rules is prohibiting insurers from using nonquantitative treatment limitations (NQTLs), such as prior authorization requirements and other utilization management, which are more restrictive than the predominant NQTLs applied to medical/surgical benefits in the same classification. Various aspects of the new rules take effect beginning as early as January 1, 2025.

The Biden-Harris Administration’s American Rescue Plan Act of 2021 provided that, through Medicaid block grants, the government offers states a new option for supporting community-based mobile crisis intervention services for beneficiaries. Mobile crisis intervention services are essential to providing rapid responses to individuals where they are located when they are experiencing a mental health or SUD crisis. These mobile services are made available 24/7/365 and are staffed with appropriately qualified behavioral health providers trained to manage such interventions. As with the 19 other states and the District of Columbia before it, the Centers for Medicare and Medicaid Services’ (CMS’s) approval of the New Hampshire State Plan Amendment means that the state will also receive Medicaid funding to directly connect beneficiaries to specialized mental health services and provide follow-up check-ins for individuals experiencing a mental health or SUD crisis.

In accordance with the Biden-Harris Administration’s ongoing effort to support programs in furtherance of the ACA’s implementation, it recently announced plans to award a new $100 million tranche of funds to organizations that serve as Navigators. Navigators offer free assistance to individuals residing in underserved communities, as well as others, to find and enroll in affordable health coverage made available through the DHHS sponsored Marketplace accessible through healthcare.gov. Navigators can also assist individuals with obtaining Children’s Health Insurance Program (CHIP) coverage if applicable. CMS is awarding these grants in advance of the Marketplace open enrollment period that begins November 1.

Florida and Texas have both implemented laws requiring certain hospitals to inquire as to patients’ immigration status when seeking care. Florida’s statute, adopted in 2023, mandates that hospitals receiving Medicaid payments query patients about their immigration status. In August, Governor Abbott of Texas took similar measures by signing an Executive Order that requires hospitals operating in Texas to collect and report the frequency and cost of certain services, including inpatient discharges and ED visits, involving patients present in the U.S. unlawfully. Hospitals participating in Medicare in both states are still required by Emergency Medical Treatment & Labor Act (EMTALA) to medically screen all persons seeking emergency care and provide necessary stabilizing treatment to those who have an emergency condition, regardless of ability to pay or insurance status. Under both state laws, hospitals must also inform patients during the course of collecting immigration status information that their responses will not affect their ability to receive care. Nonetheless, the law may have a chilling effect and deter patients from ever seeking needed care from hospitals in the first place. In that regard, while Florida hospitals must also indicate that the patient’s responses will not result in a report to immigration authorities, the Texas Executive Order is silent on this point.