On June 5, 2020, executive directors from 14 state-based insurance marketplaces (SBM) sent a letter to Congressional leaders voicing support for federal efforts to reinforce insurance markets during the COVID-19 pandemic.
As Congress and the Trump Administration propose strategies to address surprise balance billing – charges for unexpected, out-of-network medical care – states have significant experience in implementing surprise billing laws that can inform the discussion. Importantly, state authority cannot protect individuals covered by self-insured plans, which are pre-empted by Employee Retirement Income Security Act (ERISA,) from state oversight. To extend protections to consumers covered by these plans federal action is needed either through mandated protections or a change in law to enable states’ laws to apply toward ERISA plans.
States’ approaches to addressing surprise balance bills vary in how they:
- Define what services are covered by these protections;
- Address how reimbursement for services should be resolved; and
- Define provider and insurer transparency requirements.
Through National Academy for State Health Policy’s (NASHP) work with states, it has identified the following themes and lessons from state laws and experiences that could help inform future federal action on surprise balance bills.
Broadly define services covered by the law.
Balance billing protections are strongest when they extend to both all emergency circumstances and situations where the consumer does not have control over the out-of-network (OON) services provided. Such situations can occur without consent of the patient when an in-network physician is unavailable, because of an unforeseen medical situation, and/or because of a direct referral to an OON provider or facility rendered by an in-network provider. Surprise balance billing laws that include provisions to extend protections broadly across multiple provider and facility types, including specialists, labs, imaging centers, and air and land ambulance transport, offer the strongest consumer protections.
Consider multiple factors when determining the law’s dispute resolution process.
Essentially, state laws take two approaches to resolve billing disputes for surprise balance bills – setting a specific reimbursement rate for such bills and/or defining an arbitration process through which providers and insurers can resolve payment disputes. Because many state balance billing laws are nascent — and have been implemented during a time of considerable policy change affecting health care markets — there is a lack of evidence identifying the ultimate effects, either positive or negative, of either approach on state health insurance markets, including their impact on premium costs and provider network composition. Both approaches have challenges. Setting reimbursement rates for balance bills can be challenging given the multiple stakeholders involved and there is time and expense to consider in establishing fair mediation or arbitration systems. Whatever strategy Congress adopts, states’ experiences suggests the following factors for consideration:
- Remove consumers from billing disputes. To maximize consumer protection from surprise balance bills, the process for resolving reimbursements should be kept between the insurer, the provider, and any agency appointed to aid in resolution. To encourage this, additional requirements may be put in place to foster direct communication between providers and insurers, such as a requirement that insurers alert providers about what, if any, ability they will have to balance bill for services rendered to the insurer’s beneficiary. (For example, multiple states require insurers to include this information in their Explanation of Benefits sent to providers.)
- Use of data sources that leverage claims data. By using this data, such as that collected by all-payer claims databases (APCDs), reference price amounts for negotiations for medical bills will be based on actual paid amounts, rather than billed amounts. The latter may lead to inflated rates and higher health care spending. However, not all states have APCDs. Including funding to support state APCD programs could be an impetus to improve access to needed claims data in every state. To assure the most robust data collection, however, requires Congressional action to amend ERISA or provide other means for states to mandate the collection of claims data from self-funded plans. The Supreme Court’s ruling in Gobeille v. Liberty Mutual currently prohibits such requirements. While states do encourage voluntary reporting with some success, a mandate would assure more consistency in reporting. One of the issues identified in the Gobeille decision was the burden on self-funded plans created by different reporting requirements in different states. Including reference to the common data layout developed by states would resolve that reporting burden question.
- Inadvertent effects on provider networks and contracts. The ultimate reimbursement rates paid to resolve surprise balance bills should provide sufficient compensation to providers, without incentivizing providers to stay OON. For example, a benchmark that provides payments set too high may incent providers to remain OON. However, payments set too low may impose negative impacts on providers already operating on the margins. To protect against the latter, reimbursement calculations may consider a variety of factors, including average payment amounts for similar services, geographic cost variation, provider experience, or other factors unique to the situation of the service performed.
- Set a fixed amount for consumer cost sharing. This added protection will guard consumers from potentially exorbitant out-of-pocket costs in the case that final reimbursement rate decisions on a balance bill result in large out-of-pocket cost-sharing for services from deductibles, coinsurance, etc.
Include prohibitions on billing practice and hold harmless protections.
The most protective strategy would be an explicit prohibition on the part of providers or insurers from balance billing patients. While this should absolve consumers from the surprise billing burden, the law should also be clear in holding consumers harmless in situations where a balance bill is being negotiated between insurers and providers. This may take the form of specifying what form of contact, if any, insurers and providers may take with consumers regarding billing disputes and prohibiting certain actions, like credit reporting, against consumers.
Encourage enforcement through federal penalties.
Because of their limited jurisdiction over providers and certain health plans, enforcing surprise billing protections has been a challenge for some states. A successful federal law would include an enforcement mechanism that would support additional compliance with surprise balance billing laws.
Include deference to existing state laws.
States, including those with robust balance billing protections, have taken very different approaches to crafting their laws. This wide variation reflects states’ diligent and deliberate work to find solutions to surprise balance billing that work best for their markets.
States’ experiences can inform Congressional proposals and deliberations to address balance billing – from requiring transparency about networks and service costs to establishing the processes to determine the reimbursement rate for an OON provider. States have acted to protect consumers, experimenting with a variety of strategies to protect consumers from unexpected financial exposure. Federal action can extend the reach of those protections to include consumers covered by self-funded, employer-based insurance, but it should consider how any new federal law will impact state progress in this important arena of consumer protection.
Unrelenting and unpredictable increases in prescription drug prices have spurred states to try to unlock the black box of manufacturer pricing strategies by requiring disclosure of how prices are set and how rebates are handled throughout the supply chain.
Six states already have transparency laws on their books and almost two dozen more have introduced transparency bills during the 2019 session. In 2017, Maryland enacted a first-in-the-nation law prohibiting price gouging by drug manufacturers. Though the law is tied up in legal challenges, other states have introduced related bills to curb rapid and large drug price increases.
On the heels of ongoing state actions, federal lawmakers introduced a number of similar bills in Congress this month. These bills are able to leverage enforcement mechanisms beyond those available to states. For example, Sen. Richard Durbin (IL) and Rep. Jared Golden (ME) have introduced the Forcing Limits on Abusive and Tumultuous (FLAT) Prices Act. FLAT would require companies to report price hikes and would limit the market exclusivity period granted with a drug patent if the price of the drug goes up more than 10 percent in one year, 18 percent in two years, or 25 percent in three years. Failure to report price hikes would limit a drug’s exclusivity period further.
Sen. Ron Wyden (OR) also introduced several transparency bills. The Stopping the Pharmaceutical Industry from Keeping Drugs Expensive (SPIKE) Act requires the Health and Human Services secretary to request price justifications from manufacturers if prices increases surpass a threshold of 100 percent over one year or 300 percent over five years. Justification is also required if a drug has a more modest price increase yet falls within the top 50th percentile of Medicare or Medicaid spending. The bill allows manufacturers to forego reporting if they lower their prices.
Wyden also followed states’ leads in pursuing transparency around undisclosed rebates that pharmacy benefit managers (PBMs) negotiate with manufacturers. (Click here for a comparison of 31 PBM laws passed by 20 states.) Wyden’s Creating Transparency to Have Drug Rebates Unlocked (C-THRU) Act requires reporting by PBMs on the total amount of rebates they receive. Following an initial two years of reporting on these rebates, the law would establish a yet-to-be-determined percentage of rebates that PBMs must pass through to health plans in order to lower premiums or other consumer cost sharing.
Last October, Congressional legislation mirrored state laws when two federal bills regulating PBMs became law. Both federal laws prohibit gag clauses — once common provisions in PBM’s contracts with pharmacists that prevented them from disclosing lower-cost drug options to consumers. One bill prohibits gag clauses under Medicare Part D starting in 2020 and the other, affecting private insurance markets, went into effect immediately.
Thirty-three states had outlawed gag clauses before passage of the federal ban, another example of how state initiatives are now reflected in federal law. To track state activity to bring down drug costs, visit the National Academy for State Health Policy’s Center for State Rx Drug Pricing.
The country’s opioid crisis has had a devastating effect on women, children, and families, and continues to strain state health, foster care, and social service agency budgets. A flurry of bills has recently been introduced in Congress to prevent or reduce the effects of the opioid crisis and many directly impact families and children.
The bills provide key insights into Congressional efforts to help states tackle the opioid crisis. In the past month, the House passed the omnibus SUPPORT for Patients and Communities Act by a resounding vote of 396-14, and a number of other related bills have recently passed their committees. Additionally, the Senate Health, Education, Labor and Pensions (HELP) Committee advanced the Opioid Crisis Response Act of 2018. These bills support families and children affected by opioid use disorder (OUD) and are an early indication of what programs may win approval in the coming weeks. Two key approaches stand out:
- Promotion of innovative, family-centered care models that serve women and infants together; and
- A focus on data collection and research related to the needs and experiences of children and youth.
Innovative Care Models Promoted in the Proposed Legislation
Care delivery models that address the complex needs of families and children affected by opioid use are key to promoting recovery among parents and mitigating long-term impacts on children’s health.
The Senate’s Opioid Crisis Response Act of 2018 funds family-centered, residential treatment programs that serve women and infants together and provides grants and technical assistance to states to implement plans of safe care for substance-exposed infants.
- The bill also authorizes a program to support substance use disorder (SUD) prevention and recovery services for children, adolescents, and young adults, and requires the US Department of Health and Human Services (HHS) to identify and disseminate best practices for serving this population in collaboration with the US Department of Education.
- Additionally, it provides demonstration grants to better integrate mental health care into schools — an important delivery site of care for children. By integrating mental health services into schools, states can promote access to services and support for children affected by trauma, including parental opioid use.
The House SUPPORT for Patients and Communities Act would streamline services for pregnant and postpartum woman by enabling Medicaid financing of pregnancy-related services in SUD treatment facilities. It would also make it easier for Medicaid to finance community-based facilities where infants with neonatal abstinence syndrome could receive treatment along with their mothers. The bill also requires HHS to issue guidance and conduct studies to improve care for these populations.
Data collection and research into the opioid epidemic can shed light on the scope of the problem and opioid use trends, and they are critical for guiding policymaking and targeting effective interventions.
- The SUPPORT for Patients and Communities Act requires the Surgeon General to submit a report to Congress on the public health effects of the rise of synthetic drug use among individuals age 12 to 18. States can use this information to guide prevention efforts and target services and supports to address synthetic drug use and its impact on adolescents’ health.
- The Opioid Crisis Response Act supports data collection and research on prenatal substance misuse, including the long-term outcomes of children affected by neonatal abstinence syndrome. It also permits the Centers for Disease Control and Prevention to collect and report data on adverse childhood experiences. These data and research could inform state decisions about resource allocation for OUD prevention or treatment services for infants, children, and families.
Many of these and other bills have bipartisan support, but it remains to be seen if these or other bills will be enacted. The strategies proposed in these bills were also discussed at a recent meeting about SUD and families for state and local officials from Maine, Mississippi, and West Virginia hosted by the Association of State and Territorial Health Officials, the National Academy for State Health Policy (NASHP), the National Association of County & City Health Officials, and the National Conference of State Legislatures as part of a cooperative agreement with the Health Resources and Services Administration.
Developing services for infants, children, and families is already underway in states, and new innovations and planning will begin if these bills become law. To learn more about how states are working to meet the needs of women, children, and families affected by SUD, attend the following sessions at NASHP’s Annual State Health Policy Conference, Aug. 15-18, 2018 in Jacksonville, FL:
- Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder, a day-long preconference on Aug. 15, 2018; and
- Staying Afloat: Keeping Moms Connected to Opioid and Substance Abuse Services 3:30-5 p.m. Thursday, Aug. 16, 2018
Stay tuned for two upcoming NASHP issue briefs and national webinars exploring this issue, scheduled for late summer and early fall.
In early January, the National Academy for State Health Policy (NASHP) asked all state Children’s Health Insurance Program (CHIP) and Medicaid officials:
- How state CHIP funding exhaustion dates and contingency planning had changed as a result of the Dec. 22, 2017, continuing resolution that provided states with a short-term allotment of $2.85 billion, and
- What has been impact of the extended uncertainty about long-term, predictable funding on states and their CHIP programs.
The following is a summary of the information shared by 34 states whose officials responded to the poll.
Estimating the Exhaustion of Federal CHIP Funds
Given the temporary changes to the allocation of redistribution funds, states are uncertain how much future federal funding they can count on to keep their CHIP programs operational. The officials shared estimates of when their state may exhaust federal funds with NASHP on the condition of confidentiality.
- Eleven states anticipate exhausting their funds sometime in February 2018
- Ten states anticipate exhausting their funds sometime in March 2018
State contingency plans evolve with the emerging information from the Centers for Medicare & Medicaid Services (CMS) and with potential legislative action from Congress, which must pass a financial package by Jan. 19, 2018, to avoid a federal government shutdown. CMS officials have told states that future redistribution funds cannot be guaranteed and, as expected, state officials hope Congress will take action to provide long-term, predictable funding soon. Without Congressional action, there are states that may need to either freeze enrollment or initiate disenrollment by the end of January or early February.
The Impact of Prolonged Uncertainty
The impact of sustained uncertainty for the future of CHIP varies across states. Some officials report they face more significant and immediate implications than others, but all states are experiencing challenges operating a health coverage program without guaranteed funding. Here are some key budgetary and program concerns:
- Continued uncertainty has a significant impact on budgeting and planning for state resources. Should a state assume that Congress will extend CHIP? How much money should states budget for children’s coverage – enough to ensure they match CHIP dollars? A higher level of funding to provide state matching dollars for more children in Medicaid? If so, where do those funds come from?
- Should states with biennial legislative sessions convene special sessions? If so, when should they address the potential changes in states budget as a result of changes to federal funding for CHIP?
Limited Medicaid and CHIP resources are stretched thin:
- Agency staff have focused on contingency planning, budgeting, and keeping the program operational rather than make additional improvements to CHIP or other state health initiatives, such as delivery system reforms and eligibility and other information technology systems improvements.
- For months, a significant amount of staff resources has been devoted to communications and outreach to families, stakeholders and partners (including health plans, providers, contractors, vendors, and community-based organizations) to ensure they have accurate and current information.
- Uncertainty has delayed implementation of new state laws – both laws related to the CHIP program and to other health programs because the responsibility for implementing the laws falls to the same agency officials who must focus on CHIP.
Loss of participating providers and increased utilization of the delivery system:
- Although not wide-spread yet, there are reports of states losing participating providers from health plans that contract with CHIP due to the uncertainty of future funding for the program.
- There is an increased demand from families seeking primary care and specialty health services for their children while the program is still operational. This has been taxing to the delivery system in some areas and also results in an increase in spending that more rapidly depletes the available funding.
- Given the time required to make significant eligibility and claims systems changes, some states have had to make the changes even though they have not had to implement them yet. This has resulted in expenditures for staff and contractor/vendor time, as well as the cost of systems changes, even though these actions may not be needed if Congress ultimately extends the program.
States’ responses to NASHP’s poll underscore the fact that Congressional delay in extending the CHIP program’s funding could soon result in children losing their health coverage and highlight the systemic implications for states. Budgetary, systems, provider network, and agency work delays will likely affect states and their coverage programs for months after the uncertainty is resolved.
On Dec. 21, Congress passed a continuing resolution (CR) bill to keep the federal government operational through Jan. 19, 2018, and it includes new, short-term federal funding for the Children’s Health Insurance Program (CHIP). Specifically, the CR:
- Provides $2.85 billion in new federal allotments to states for CHIP for the period from Oct. 1, 2017, to March 31, 2018.
- Extends the CHIP redistribution special rule for allocating existing funds to certain shortfall states through the first half of FFY 2018. This special rule is known as the “CHIP fix” and was originally established in the Dec. 8 CR.
The Centers for Medicare & Medicaid Services (CMS) has provided information about each state’s preliminary allotment amounts from the $2.85 billion in new federal CHIP funding. However, while there is new federal CHIP funding for states with the extension of the Dec. 8 reallocation of the redistribution funding and differing rates of state spending in their CHIP programs, it is unclear how long these new CR provisions in combination will actually allow all states to continue operating their CHIP programs.
Discussions about providing a longer-term funding extension for CHIP could be a part of the funding package that would need to pass by Jan. 19, 2018, to keep the federal government operating. NASHP will be watching Congressional action closely and will provide updates in the coming weeks.
(Note: An earlier version of the CR introduced in the House on Dec. 13 had contained a five-year funding extension for CHIP.)
How long would you drive your car with its gasoline gauge on empty when it’s full of people you care about as you speed along a highway? That was the analogy used by Children’s Health Insurance Program (CHIP) and Medicaid officials during National Academy for State Health Policy’s (NASHP) annual conference held late last month.
Congress has repeatedly promised state officials that there is broad support for CHIP, and that new funds will be available soon and they should just hold on until then. However, it has been over a month since federal CHIP funding expired and it is still unclear if and when Congress will successfully pass a bill to provide more federal funding.
On Nov. 3, 2017, the House of Representatives passed H.R. 3922, a bill combining funding extensions for both CHIP and community health centers. The bill passed the House by a vote of 242-174, with most Democrats voting against it because of their opposition how to the bill is paid for. The pay-fors or off-sets in the House bill include taking money away from the Affordable Care Act’s (ACA) public health and prevention fund and increasing premiums for higher-income Medicare enrollees. Given the current partisan divide over the funding off-sets, the bill’s future remains uncertain.
In the absence of certainty over its future and funding, state officials must weigh multiple factors in making difficult decisions in the weeks ahead. As stewards of health coverage for low- to moderate-income children and pregnant women who depend on CHIP, state officials are first and foremost considering what is currently best for families and are trying to maintain this coverage for as long as possible.
Officials are actively scrutinizing their state’s CHIP finances to determine how long their current funding will last and are trying to figure out if there is any way within their already stressed budgets to extend CHIP once federal carryover and redistribution funds have been exhausted. For example, Arizona is one of the first states expected to exhaust their available federal funds and officials there are considering using money from the state’s “rainy day fund” to continue CHIP coverage. This is not an option for most, as a growing number of states are struggling to address budget shortfalls or address unexpected costs resulting from multiple natural disasters that occurred this year.
Reality is setting in as an increasing number states (MN, AZ, WA, CA, OR, UT, and DC) exhaust their available 2017 carryover allotment and receive their limited redistribution funds from the Centers for Medicare & Medicaid Services (CMS). Without federal funds, most states will need to shut down their CHIP programs and in doing so must consider state notification requirements, costs that the state will incur to close this program, and more. So, why haven’t states sent notices to families warning that the program will shut down? During NASHP’s conference, officials voiced concerns that termination notices could create unnecessary panic for families that could result in far-reaching ramifications that may take months or years to nullify.
Officials know from some states’ experience from freezing enrollment and establishing wait lists for CHIP approximately15 years ago when the block grant’s funding was not adequate that those changes can instill distrust of the program for families. Officials fear parents may disenroll their children sooner than necessary or not renew their coverage. There is also a concern that knowing a child’s coverage is limited will influence medical care decisions, particularly for longer-term treatments. And if Congress does extend federal funding for CHIP after termination notices are sent, states will need to send another notice letting families know they can re-enroll. Officials fear that not all families will re-enroll their children in CHIP if they perceive it to offer unstable coverage. And finally, there is a cost to states to develop, generate, and send notices.
Unfortunately, there are states that expect to exhaust their CHIP funds in December and January that will have no other option than to disenroll children and pregnant women from coverage. As a result, state officials’ questions about their own next steps have increased and intensified. Such questions include:
- What is more important? 1) Giving families more notice and time to plan and research other possible coverage options, which risks potential unnecessary panic or, 2) Minimize panic and only alert families when absolutely necessary?
- What kind of assistance needs to be available to families who are losing CHIP coverage so they can weigh and navigate the potential other coverage options that may be available to them? And, how to pay for that assistance considering states did not assume this would be necessary in designing their budgets and given that the Trump Administration has cut outreach funds for the Marketplaces?
- hould states handle the timing of possibly closing down CHIP programs for pregnant women given their time sensitive, ongoing needs for medical attention?
- What needs to be done to ensure children are transferred successfully from CHIP to the Marketplace so families can enroll them in Qualified Health Plans (QHPs) if they are eligible to receive subsidies? Is it possible to have a data feedback loop from the federally-facilitated marketplace to know if CHIP children are in fact enrolling in QHPs or need further assistance?
State officials are frustrated that they find themselves preparing to shut down a program that has had such success. During a NASHP conference session, state officials offered a snapshot of their unique children’s coverage programs and highlighted the impact of CHIP in their states. Comparing data points from 1997 (the year CHIP was enacted) to today, states shared statistics showing the decline in uninsured children’s rates as well as increases in their access to care, particularly for primary care. States have also made strides to integrate CHIP with other programs so families can experience a continuum of coverage that could soon be significantly disrupted.
Just because states have yet to alert families that CHIP is in jeopardy doesn’t mean officials are not feeling the pressure of their gas tanks approaching empty. States are anxious for Congress to come together as its members have done throughout the history of CHIP to find a bipartisan agreement that provides funding certainty to ensure families and pregnant women do not experience unnecessary panic or loss of coverage.
Congress missed the Sept. 30, 2017, deadline to extend federal funding for the Children’s Health Insurance Program (CHIP), so there is currently no new or guaranteed future federal support for the program that covers an estimated 9 million children. There are two proposed bills to reauthorize CHIP – the Senate’s KIDS Act of 2017 and the House of Representative’s Healthy Kids Act – that were approved by their respective committees to advance them in the legislative process for consideration by the full Senate and House.
Meanwhile, the first states to exhaust their annual CHIP allotments are now working with the Centers for Medicare & Medicaid Services (CMS) to secure short-term funding to continue their programs as long as possible.
Financing for CHIP, a block grant-funded program, was most recently appropriated through the Medicare Access and CHIP Reauthorization Act (MACRA) passed in 2015. MACRA included two years (FFY 2016 and 2017) of CHIP funding allocated to states through annual allotments. States spend their allotted CHIP dollars at different rates for many reasons, including geographic differences in health care costs; varied types of service delivery; and what benefits are covered by a state’s CHIP program.
As a result, at the end of this fiscal year, states have varying amounts of unspent CHIP funds remaining. Because there are currently no newly-appropriated federal dollars supporting CHIP, states can use the unspent funds from FFY 2017 to continue to support their CHIP programs.
However, there is a “claw-back” provision in MACRA that requires states to reduce their FFY 2017 carryover or unspent allotment by one-third and return it to the federal treasury. The claw-back provision was designed to reduce MACRA’s overall cost and the amount Congress needed to “off-set” or “pay for” the program in order to pass the bill. Losing a third of the carryover funds is a serious challenge to states because they need this money to continue their CHIP programs in the absence of Congressional action to extend the program.
The Administration predicts a national CHIP shortfall of $13 billion in fiscal year 2018 without a CHIP extension. There is approximately $3 billion in unspent CHIP dollars from FFY 2016 that will be redistributed proportionately across all states as their CHIP carryover funds run out, but it is not clear exactly how much each state will receive. To claim their portion of the redistributed funds, states must contact CMS the month before they exhaust their FFY 2017 carryover money. CMS will then provide states with information and calculations of expected funds, which will be provided through a monthly grant. Federal estimates suggest on average each state will be able to fund one or two more months of CHIP, but this projection doesn’t take into consideration unanticipated costs, such as increased enrollment or high utilization.
Minnesota, which is the first state to exhaust its available 2017 carryover funds, has received a redistribution payment. Additional states have begun conversations with CMS to better understand what they can expect to receive. State officials report frustration at the prospect of receiving their portions of the redistribution funds on a monthly, piecemeal basis rather than a lump sum. It leaves them with limited capacity to plan the final weeks of their programs’ funding. And while the individual calls with CMS provide state-by-state technical assistance, the lack of formal guidance on the payment of redistribution funds lacks transparency and eliminates the capacity to plan with peers for contingencies, such as when or how states should notify families that the program may be ending.
State officials remain optimistic that Congress will take action to re-establish federal CHIP funding, but patience is beginning to wane as their remaining CHIP funds are depleted. The uncertainty around CHIP funding may also influence how families act – will people use more services now because they fear an end to the program? How will new enrollment and renewals be affected? These questions complicate a state’s ability to budget and predict when funds will be exhausted.
Additionally, states have legal obligations to notify families if the program is going to expire. State officials hope Congress will act soon, but in the meantime they must develop contingency plans, knowing that worst-case scenarios that would include dis-enrolling children need to be developed with a careful approach so as not to unnecessarily alarm families. But the clock is ticking, and states need the certainty only Congressional action can provide.
As lawmakers debate how to stabilize the individual market, one of the key sticking points is whether to fund cost-sharing reduction (CSR) payments instituted under the Affordable Care Act. CSRs subsidize insurance policies that offer lower-cost coverage to low-income consumers. This graphic offers a simple explanation of the limited choices states faced as they set rates for 2018 in this uncertain environment.
Infographic: Will Washington fund CSR subsidies to stabilize the health insurance markets?