/ en Fri, 25 Apr 2025 11:13:46 -0500 Mon, 21 Apr 25 16:41:00 -0500 /fact-sheets/2025-02-07-fact-sheet-telehealth <div class="container"><div class="row"><div class="col-md-8"><p><img src="/sites/default/files/inline-images/New-normal-vast-majority-of-hospitls-continue-to-use-telehealth.png" data-entity-uuid="4982c706-02b2-4af6-8ee7-9d6bea526a6e" data-entity-type="file" alt="New normal: vast majority of hospitals continue to use telehealth. Percent of hospitals offering telehealth services, 2018 to 2022. 2018: 72.6%. 2019: 78.3%. 2020: 85.1%. 2021: 86.0%. 2022: 86.9%. Note: AHA analysis of survey respondents to the 2018-2022 AHA Annual Survey. Telehealth services may be offered through the health system, a joint venture, or through the hospital itself." width="377" height="408" class="align-right">Telehealth is now a routine way for patients to access health care services and for providers in remote and other areas to access specialty consults that expand their ability to treat patients in their local communities. Telehealth adoption has grown significantly over the past five years due to waivers that enabled more services to be delivered via telehealth under more circumstances and for the providers of those services to be reimbursed. It has been proven safe and effective, and both patients and clinicians report high satisfaction. Prior concerns that telehealth would add utilization — and therefore cost — to the health care system have not been borne out.</p><p>Unfortunately, without congressional action, patients and providers may soon lose access to important telehealth services. <span><strong>We urge Congress to not send the health care system backward and instead make permanent the telehealth flexibilities granted during the pandemic.</strong></span></p><h2>AHA Position</h2><p>As outlined in our <a href="/fact-sheets/2025-02-07-fact-sheet-2025-telehealth-advocacy-agenda">telehealth advocacy agenda</a>, the AHA supports:</p><ul><li><span><strong>Permanently adopting expanded access to telehealth:</strong></span> Permanent adoption of telehealth flexibilities will provide a firm foundation to preserve access and support further reform. We urge Congress to lift geographic and originating site restrictions, allow Rural Health Clinics and Federally Qualified Health Centers to serve as distant sites, expand practitioners who can provide telehealth, remove arbitrary in-person visit requirements for behavioral health, and allow the continuation of audio-only telehealth services.</li><li><span><strong>Expanding the telehealth workforce:</strong></span> Expanding the telehealth workforce will serve as a force multiplier to increase access for areas with health care staffing shortages. Specific policies (like codifying virtual supervision flexibilities), removing barriers to cross-state licensure and eliminating dangerous reporting requirements (like provider home addresses) will increase the telehealth workforce.</li><li><span><strong>Ensuring fair and adequate telehealth reimbursement:</strong></span> Virtual care still has costs, including for both personnel, technology, and office space out of which many telehealth providers work. Appropriate reimbursement is necessary to preserve increased access to care.</li><li><span><strong>Supporting telehealth for rural and medically underserved areas:</strong></span> One barrier to expanding telehealth to these populations has been a lack of access to enabling technologies (like broadband, reliable Wi-Fi or smartphones), as well as education to support digital literacy. As such, we encourage cross-agency collaboration to develop training and infrastructure investment. Additionally, arbitrary requirements, like mandatory in-person visit requirements for behavioral health or prior to prescribing of controlled substances, have limited access for communities that may not have a practitioner available in person. We have urged for the development of a new, streamlined special registration process to waive in-person visit requirements for prescribing controlled substances.</li></ul><h2>Key Facts</h2><ul><li>Recent data from the Kaiser Family Foundation indicates that while utilization of telehealth has declined since 2020, utilization remains higher than pre-pandemic levels. In the last quarter of 2023, over 12.6% of Medicare beneficiaries received a telehealth service.<a href="#fn1"><sup>1</sup></a></li><li>There is a growing body of evidence showing that telehealth does not result in additive or duplicative care. A study of over 35 million records by Epic found that for most telehealth visits across 33 specialties, there was no need for an in-person follow-up visit within 90 days of the telehealth visit.<a href="#fn2"><sup>2</sup></a></li><li>Recent data suggest that the United States will face a physician shortage of up to 86,000 physicians by 2036.<a href="#fn3"><sup>3</sup></a> Telehealth is a critical supporting element to address the growing shortage of physicians.</li><li>Patients across geographies and settings, including both rural and urban areas, have benefited from the increased access and improved convenience provided by telehealth services since patients could receive care from their homes. In fact, data from the Office of the Assistant Secretary for Planning and Evaluation (ASPE) showed that most patients using telehealth in 2020 (92%) received telehealth from their home.<a href="#fn4"><sup>4</sup></a> >/li></li><li>The availability of audio-only telehealth is a critical option to ensure access to care when patients may not have access to technology or bandwidth for video visits. A 2021 report from ASPE found that the majority of surveyed respondents 65 and older used audio-only visits (56.5%) compared to video visits, partly driven by the fact that over 26% of Medicare beneficiaries reported not having computer or smartphone access at home.<a href="#fn5"><sup>5</sup></a></li><li>The lack of broadband infrastructure exacerbates access challenges for certain areas. The Federal Communications Commission reports that over 22% of Americans in rural areas lack access to appropriate broadband (fixed terrestrial 25/3 Mbps) compared to 1.5% in urban areas.<a href="#fn6"><sup>6</sup></a></li><li>Misperceptions about telehealth contributing to fraud, waste and abuse are not supported by data. A recent Office of the Inspector General report found that only 0.2% of all telehealth providers were “potentially high-risk” for fraud, waste and abuse previously.<a href="#fn7"><sup>7</sup></a> Policies should support the 99.8% of providers safely and compliantly delivering services.</li></ul><h2>Resources</h2><ul><li><a href="/news/perspective/2024-10-18-taking-action-extend-telehealth-and-hospital-home-programs">Taking Action to Extend Telehealth and Hospital-at-home Programs</a></li><li><a href="/lettercomment/2024-03-20-aha-urges-cms-remove-telehealth-provider-home-address-reporting-requirements">CMS Urged to Remove Telehealth Provider Home Address Reporting Requirements</a></li><li><a href="/lettercomment/2023-09-11-aha-comments-cms-physician-fee-schedule-proposed-rule-calendar-year-2024">AHA Comments on CMS’s Physician Fee Schedule Proposed Rule for Calendar Year 2024</a></li><li><a href="/news/headline/2024-04-10-aha-urges-congress-make-telehealth-flexibilities-permanent">AHA urges Congress to make telehealth flexibilities permanent</a></li><li><a href="/2024-08-12-aha-comments-340b-drug-pricing-program-irf-payments-physician-fee-schedule-and-telehealth">AHA Comments on 340B Drug Pricing Program, IRF Payments, Physician Fee Schedule and Telehealth</a></li><li><a href="/2023-10-10-aha-letter-support-senate-connect-health-act-2023-s-2016">AHA Letter of Support for Senate CONNECT Health Act of 2023 (S. 2016)</a></li><li><a href="/lettercomment/2023-01-30-ahas-feedback-senate-re-connect-act">AHA’s Feedback to the Senate Re: The CONNECT Act</a></li><li><a href="/lettercomment/2022-12-01-aha-letter-dea-regarding-request-release-special-registration-telemedicine-regulation">AHA Comments on the SUPPORT for Patients and Communities Reauthorization Act</a></li><li><a href>AHA Letter to DEA Regarding Request for Release of Special Registration for Telemedicine Regulation</a></li></ul><hr><h3>Notes</h3><ol><li id="fn1"><a href="https://www.kff.org/medicare/issue-brief/what-to-know-about-medicare-coverage-of-telehealth/" target="_blank">https://www.kff.org/medicare/issue-brief/what-to-know-about-medicare-coverage-of-telehealth/</a></li><li id="fn2"><a href="https://epicresearch.org/articles/telehealth-visits-unlikely-to-require-in-person-follow-up-within-90-days" target="_blank">https://epicresearch.org/articles/telehealth-visits-unlikely-to-require-in-person-follow-up-within-90-days</a></li><li id="fn3"><a href="https://www.aamc.org/media/75236/download?attachment" target="_blank">https://www.aamc.org/media/75236/download?attachment</a></li><li id="fn4"><a href="https://aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf" target="_blank">https://aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf</a></li><li id="fn5"><a href="https://aspe.hhs.gov/sites/default/files/documents/4e1853c0b4885112b2994680a58af9ed/telehealth-hps-ib.pdf target=">https://aspe.hhs.gov/sites/default/files/documents/4e1853c0b4885112b2994680a58af9ed/telehealth-hps-ib.pdf</a></li><li id="fn6"><a href="https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2020-broadband-deployment-report" target="_blank">https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2020-broadband-deployment-report</a></li><li id="fn7"><a href="https://oig.hhs.gov/oei/reports/OEI-02-20-00720.pdf" target="_blank">https://oig.hhs.gov/oei/reports/OEI-02-20-00720.pdf</a></li></ol></div><div class="col-md-4"><a href="/system/files/media/file/2025/02/Fact-Sheet-Telehealth-20250207_0.pdf" target="_blank" title="Click here to download the Fact Sheet: Telehealth PDF." system files media file><img src="/sites/default/files/2025-04/cover-fact-sheet-telehealth-april-2025.png" data-entity-uuid data-entity-type="file" alt="Fact Sheet: Telehealth page 1." width="695" height="899"></a></div></div></div> h2 { color: #003087; } h3 { color: #9d2235; } Mon, 21 Apr 2025 16:41:00 -0500 Fact Sheets /fact-sheets/2025-04-14-whats-stake-medicaid-covers-people-you-know <div class="container"><div class="row"><div class="col-md-8"><p><a href="/system/files/media/file/2025/04/Whats-at-Stake-Medicaid-covers-the-people-you-know.pdf" target="_blank" title="Click here to download the What's at Stake: Medicaid covers the people you know PDF."><img src="/sites/default/files/inline-images/Whats-at-Stake-Medicaid-covers-the-people-you-know.png" data-entity-uuid="01c577ea-dcda-41cc-8c50-1f1e1bfd8db4" data-entity-type="file" alt="What's at Stake: Medicaid covers the people you know. The majority of U.S. residents with Medicaid coverage are children. 39% of children are covered by Medicaid. Medicaid protects access to care for rural communities. Among Medicaid beneficiaries, 47% of children and 18% of adults live in rural communities. Medicaid supports access to essential obstetrics care, behavioral health services, and primary care. 41% of births in the U.S. are covered by Medicaid. Medicaid provides access to care for low-income seniors. 13.7 million seniors in the U.S. are dually eligible for Medicare and Medicaid. Fact: Medicaid chronically underpays for services. Without supplemental payments, Medicaid fee-for-services payments nationally paid 58 cents for every dollar that hospitals spend caring for Medicaid patients, and Medicaid managed care organizations paid 65 cents. Protect Access to Care: The AHA urges Congress to reject reductions to the Medicaid program that would threaten health care access for patients." width="695" height="900"></a></p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/04/Whats-at-Stake-Medicaid-covers-the-people-you-know.pdf" target="_blank" title="Click here to download the What's at Stake: Medicaid covers the people you know PDF.">Download the Infographic PDF</a></div></div></div></div> Mon, 14 Apr 2025 10:42:17 -0500 Fact Sheets /fact-sheets/2025-04-14-protect-access-care-reject-cuts-medicaid-program-and-premium-hikes-working-families <div class="container"><div class="row"><div class="col-md-8"><p><a href="/system/files/media/file/2025/04/Protect-Access-to-Care-Reject-cuts-to-the-Medicaid-program-and-premium-hikes-on-working-families.pdf" target="_blank" title="Click here to download the Protect Access to Care: Reject cuts to the Medicaid program and premium hikes on working families PDF."><img src="/sites/default/files/inline-images/Protect-Access-to-Care-Reject-cuts-to-the-Medicaid-program-and-premium-hikes-on-working-families.png" data-entity-uuid="c001b8d1-d304-46e2-900b-524456f65c4c" data-entity-type="file" alt="Protect Access to Care: Reject cuts to the Medicaid program and premium hikes on working families. If Congress cuts Medicaid, hospitals would see significant imparts that vary by policy: Per Capita Caps for All Medicaid Population: 1-Year National Hospital Impact in 2026 -$47.6 billion; 10-Year National Hospital Impact through 2024: -$468.1 billion. Per Capita Caps for Expansion Population: 1-Year National Hospital Impact in 2026 -$18.9 billion; 10-Year National Hospital Impact through 2024: -$199.9 billion. Eliminate Enhanced FMAP for Expansion Population: 1-Year National Hospital Impact in 2026 -$32 billion; 10-Year National Hospital Impact through 2024: -$360.6 billion. Reduce FMAP Statutory Floor to 45%: 1-Year National Hospital Impact in 2026 -$7.3 billion; 10-Year National Hospital Impact through 2024: -$78.4 billion. Limit Provider Taxes to 5%: 1-Year National Hospital Impact in 2026 -$3 billion; 10-Year National Hospital Impact through 2024: -$32.8 billion. If the Enhanced Premium Tax Credits (EPTCs) expire: 2.2 million individuals are at risk of becoming uninsured in 2026; 4 million individuals are facing higher costs due to loss of Marketplace coverage in 2026; $705 average per person increase in annual premiums in 2026; -$28.2 billion reduction in spending on hospitals over 10 years." width="695" height="900"></a></p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/04/Protect-Access-to-Care-Reject-cuts-to-the-Medicaid-program-and-premium-hikes-on-working-families.pdf" target="_blank" title="Click here to download the Protect Access to Care: Reject cuts to the Medicaid program and premium hikes on working families PDF.">Download the Infographic PDF</a></div></div></div></div> Mon, 14 Apr 2025 10:10:24 -0500 Fact Sheets /2025-02-27-fact-sheet-expiration-enhanced-premium-tax-credits <div class="container"><div class="row"><div class="col-md-8"> li::marker { color:#9d2235; } <h2><span><em>The Issue</em></span></h2><p>In 2021, Congress expanded eligibility for enhanced premium tax credits (EPTCs or tax credits) to help certain individuals and families purchase insurance on the health insurance marketplaces. This change has been especially impactful for those in rural areas, who tend to face higher premiums and fewer coverage options,1 as well as those with lower incomes.</p><p>These EPTCs are scheduled to expire at the end of 2025. If they are not extended, millions of Americans will lose coverage or incur significantly higher costs. The largest disruptions would be felt by individuals and families living in rural communities that have experienced significant benefits from the expanded health care coverage.</p><h2><span><em>AHA Take</em></span></h2><p>In order to continue the life-saving care to rural and low-income patients, as well as the stability of the entire health care system, the AHA urges Congress to extend the EPTCs.</p><h2><span><em>Why?</em></span></h2><ul><li>The EPTCs helped millions of Americans purchase affordable commercial health care coverage and access necessary health care. <span><strong>The</strong> <strong>expiration of this policy would both harm the health of communities and raise individuals’ taxes via premium increases</strong></span><strong>.</strong><sup>2</sup></li><li>Analysis by KNG Consulting for the AHA shows that the expiration of the EPTCs would <span><strong>disproportionately affect those in rural areas and those with lower incomes</strong></span>. Specifically, the most rural states in America would experience, on average, a <span><strong>30% decrease in marketplace coverage and a 37% increase in their uninsured populations</strong></span>.<sup>3</sup></li><li>Rural populations have more complex health needs, experience higher average health insurance premiums, are much more likely to be uninsured, face longer travel distances to providers and have fewer health care options. <span><strong>The EPTCs are a fundamental support for critical health care access in rural communities nationwide</strong></span>.</li><li>Individuals with lower incomes and less formal education also face greater health vulnerabilities due to higher rates of chronic conditions and financial barriers to receiving timely care. <span><strong>The expiration of the EPTCs would exacerbate these existing health care comorbidities and access challenges</strong></span>.</li><li>Rural states would see higher rates of disruption in coverage, with larger percentages of residents losing marketplace coverage and becoming uninsured. <span><strong>These disruptions are particularly high in rural states that have not expanded Medicaid</strong></span>.</li></ul><img src="/sites/default/files/inline-images/image_47.png" data-entity-uuid="1f0d0920-f6b0-4485-848e-e6e5a85682a4" data-entity-type="file" alt="Image of figure 8" width="407" height="484" class="align-center"><p><sup>1</sup> <a href="https://americanscovered.org/big-for-farm-states-why-enhanced-premium-tax-credits-are-essential-for-rural-americans/" target="_blank" title="AmericansCovered.org Website"><small class="sm">americanscovered.org/big-for-farm-states-why-enhanced-premium-tax-credits-are-essential-for-rural-americans /</small></a><small class="sm">.</small><br><small class="sm"><sup>2</sup> </small><a href="https://www.kff.org/affordable-care-act/issue-brief/inflation-reduction-act-health-insurance-subsidies-what-is-their-impact-and-what-would-happen-if-they-expire/" target="_blank" title="KFF.org website"><small class="sm">kff.org/affordable-care-act/issue-brief/inflation-reduction-act-health-insurance-subsidies-what-is-their-impact-and-what-would-happenif-they-expire/</small></a><small class="sm">.</small><br><small class="sm"><sup>3</sup> Calculated as the average percent impact on coverage for the most rural states in the United States, as of 2024. See World Population Review, State Rankings, Most Rural States 2024,” at </small><a href="https://worldpopulationreview.com/state-rankings/most-rural-states" target="_blank" title="Worldpopulation.com website"><small class="sm">worldpopulationreview.com/state-rankings/most-rural-states</small></a><small class="sm">.</small></p></div><div class="col-md-4"><a href="/system/files/media/file/2025/02/fact-sheet-expiration-of-the-enhanced-premium-tax-credits.pdf"><img src="/sites/default/files/inline-images/cover-fact-sheet-expiration-of-the-enhanced-premium-tax-credits.png" data-entity-uuid="9ca02e14-416c-474d-86cf-5394575e1fc9" data-entity-type="file" alt="Fact Sheet cover image" width="682" height="882"></a></div></div></div> Thu, 27 Feb 2025 13:48:48 -0600 Fact Sheets /fact-sheets/2025-02-20-fact-sheet-facility-fees <div class="container"><div class="row"><div class="col-md-8"><h2><span><em>The Issue</em></span></h2><p>Facility fees are the portion of a health care treatment bill that covers all the costs of delivering patient care, except for those that are billed by physicians and other professionals. Congress has introduced several pieces of legislation that would limit hospitals’ ability to charge these fees in the context of Medicare hospital outpatient payments (also known as “site-neutral” provisions). These proposals would cut anywhere from approximately $3 billion to $180 billion from hospitals over 10 years without providing any alternative mechanism for funding the essential health care services that only hospitals provide. Increasingly, policymakers are also looking at policies to limit facility fees in the context of commercial coverage.</p><h2><span><em>AHA Take</em></span></h2><p>The AHA urges Congress to oppose any legislation that would cut resources to hospitals through the use of facility fees to help finance the care they provide to their communities.</p><h2><span><em>Why?</em></span></h2><ul><li>Facility fees provide hospitals with the resources necessary to make available the high-acuity services only they can provide on a 24/7 basis, such as emergency and trauma care. This includes around the- clock nursing and physician services, medical equipment, drug therapies and maintaining critical building and community infrastructure.</li><li>Hospital outpatient departments and affiliated physician offices are not the same as independent physician offices and other ambulatory sites of care. They care for sicker patients and treat a higher rate of uninsured. They also must meet higher regulatory standards. For example, unlike most independent physician offices or ambulatory surgery centers, hospital outpatient departments and affiliated physician practices do not call 911 if their patient experiences a medical emergency. Instead, they work as an integrated system to immediately transfer the patient to the hospital emergency department or other appropriate care setting.</li><li>Facility fees are increasingly used to cover the true cost of providing physician services, which hospitals do by subsidizing physicians’ pay above the underpayment that they are reimbursed from both public and private payers. These payers have pushed physician compensation so low that many physicians have no choice but to either seek employment or require subsidies from the facilities in which they work.</li><li>Restrictions on the use of facility fees could result in hospitals having to make challenging decisions to end the provision of certain services. This would result not only in a loss of access to care in the community but also in jobs.</li></ul><h2><span><em>Key Facts</em></span></h2><p>Hospital bills cover two types of expenses — professional fees and facility fees. Professional fees cover the cost of the physician providing the care. Facility fees cover everything else — both the direct and indirect costs that allow hospitals to continue to provide comprehensive care to patients and serve the needs of their communities. However, as both Medicare and commercial payers increasingly compensate physicians below the cost of delivering care, hospitals have needed to use a portion of facility fees to subsidize physician practices. These fees may be combined into one bill or separated into multiple bills.</p><img src="/sites/default/files/inline-images/image_45.png" data-entity-uuid="28fe6d72-8d14-4593-9e8e-28274902c28f" data-entity-type="file" alt="Professional fees chart" width="850" height="525"></div><div class="col-md-4"><a href="/system/files/media/file/2025/02/fact-sheet-facility-fees.pdf"><img src="/sites/default/files/inline-images/cover-fact-sheet-facility-fees.png" data-entity-uuid="2fd7d096-f108-4c23-b2c6-8deb529a5869" data-entity-type="file" alt="Cover of Fact Sheet" width="682" height="882"></a></div></div></div> Thu, 20 Feb 2025 14:55:33 -0600 Fact Sheets /fact-sheets/2025-02-07-fact-sheet-budget-reconciliation-101 <div class="container"><div class="row"><div class="col-md-8"><h2>The Issue</h2><p>Budget reconciliation is an optional process under the Congressional Budget Act of 1974 that allows for expedited consideration of certain fiscal legislation that makes changes to mandatory spending, revenues and/or the debt limit. This special fast-track procedure is designed to reconcile current law with assumptions contained in the annual budget resolution adopted by Congress. Reconciliation legislation is privileged and cannot be filibustered in the Senate, meaning it requires only a simple majority, instead of a three-fifths majority, to pass. The contents of a reconciliation bill are tightly controlled because the process restricts the Senate’s right to unlimited debate that exists for most other legislation. The Senate’s “Byrd rule” aims to prevent the inclusion of matter considered “extraneous” to the budgetary goals of the legislation. In recent years, reconciliation has been used to enact landmark fiscal legislation on a party line basis. The most recent examples include the Tax Cuts and Jobs Act (2017), the American Rescue Plan (2021) and the Inflation Reduction Act (2022).</p><h2>Understanding the Basics</h2><h3>Step 1: Budget Resolution</h3><ul><li>Before Congress can begin work on a reconciliation bill, it must first pass a concurrent budget resolution in the House and Senate. A budget resolution serves as a roadmap to guide fiscal decision-making in Congress. Unlike other bills, it does not go to the President’s desk for signature and does not have the force of law. A budget resolution that is being used for reconciliation will contain a series of “reconciliation instructions” to various committees of jurisdiction directing them to report legislation that meets a specified fiscal target, such as requiring a committee to reduce mandatory spending by no less than a certain amount or reduce revenue by no more than a certain amount. The numerical instructions provide the fiscal goals of the legislation and cannot dictate the substance of how the committees are to meet their instructions. Nevertheless, which committees are given instructions, and the magnitude of those instructions, can be indicative of potential areas of focus.<ul><li><span><strong>Example:</strong></span> Instructions to the Energy & Commerce Committee directing them to reduce mandatory spending by a large amount opens the door to spending cuts within health programs.</li></ul></li></ul><h3>Step 2: Committees Begin Work on Reconciliation Bill</h3><ul><li>The instructed committees begin drafting legislation consistent with their instructions from the budget resolution and then move legislation through the committee process. The Budget Committee takes each committee-reported measure and combines them into a single reconciliation bill to prepare for consideration before the House or Senate.<ul><li><span><strong>Clarifying Point:</strong></span> Committees that did not receive reconciliation instructions in the budget resolution are not involved in the process. Committees cannot include subject matter outside of their jurisdiction.</li></ul></li></ul><h3>Step 3: Debate and Passage</h3><ul><li>The House and Senate have different rules that govern how legislation is considered by the full chamber. In the House, the Rules Committee will establish guidelines for debate on the bill and decide whether members will be allowed to make amendments to the bill. A reconciliation bill is passed in the House with a simple majority consistent with their typical process.</li><li>In the Senate, debate is limited to 20 hours and only 51 votes are needed to pass the bill instead of the usual 60 votes.<ul><li><span><strong>Clarifying Point:</strong></span> Even after the 20 hours of debate has expired, senators are allowed to offer amendments and make other motions on the bill. These extra votes are often referred to as “vote-a-rama.” Amendments are voted on without debate until no more amendments are offered. At that point, the Senate will vote on final passage of the reconciliation bill.</li></ul></li></ul><h3>Step 4: Resolving Differences & Final Approval</h3><ul><li>Before the reconciliation bill can be sent to the President for signature or veto, Congress must work out any remaining differences between the House and Senate bills. Once both chambers of Congress have passed an identical bill, the bill heads to the President’s desk.<ul><li><span><strong>Example:</strong></span> The House passes the reconciliation bill first and sends it to the Senate. The Senate passes amendments making changes to the bill. The House will need to vote on this new version before sending it to the President’s desk.</li></ul></li></ul><h2>Diving Deeper: The Byrd Rule</h2><h3>The Byrd Rule sets six criteria to determine whether a provision can be included in a reconciliation bill or whether it is considered extraneous.</h3><ul><li>A provision that violates any one of the six Byrd rule tests can be removed from the bill if a senator raises a Byrd rule point of order, unless 60 senators vote to waive the point of order to allow that provision to stay in the bill.<ul><li><span><strong>Clarifying Point:</strong></span> The Presiding Officer in the Senate makes the determination whether provisions are consistent with the rules, based on advice from the Senate Parliamentarian.</li><li><span><strong>Clarifying Point:</strong></span> The Byrd Rule only applies to consideration in the Senate. However, the House must be careful in crafting their bill to ensure it follows the Byrd Rules parameters otherwise it will put the bill at risk in the Senate.</li></ul></li></ul><h3>Six Criteria Used to Determine Whether a Provision is “Extraneous”:</h3><ol><li><span><strong>No Budgetary Effect:</strong></span> Provision does not change mandatory spending or revenues.</li><li><span><strong>Not in Accordance with Instructions:</strong></span> Provision increases mandatory spending or reduces revenues, and the committee is not in compliance with its instructions.</li><li><span><strong>Outside Committee Jurisdiction:</strong></span> Provision falls outside the jurisdiction of the instructed committee.</li><li><span><strong>Incidental Budgetary Effect:</strong></span> Provision produces a change in mandatory spending or revenues that is merely incidental to its other components.</li><li><span><strong>Increases Deficit Beyond the Budget Window:</strong></span> Provision would increase the deficit in any year beyond the period covered by a committee’s reconciliation instruction (usually 10 years).</li><li><span><strong>Changes to Social Security:</strong></span> Provision makes changes to Title II of the Social Security Act.</li></ol></div><div class="col-md-4"><p><a href="/system/files/media/file/2025/02/Fact-Sheet-Budget-Reconciliation-101-20250207.pdf" target="_blank" title="Click here to download the Fact Sheet: Budget Reconciliation 101 PDF."><img src="/sites/default/files/inline-images/Page-1-Fact-Sheet-Budget-Reconciliation-101-20250207.png" data-entity-uuid="f869be09-95e9-467e-8c28-e7fc30015205" data-entity-type="file" width="695" height="900"></a></p></div></div></div> h2 { color: #003087; } h3 { color: #002855; } Fri, 07 Feb 2025 14:23:32 -0600 Fact Sheets /fact-sheets/2025-02-07-fact-sheet-telehealth-waivers <div class="container"><div class="row"><div class="col-md-8"><h2>Background</h2><p>At the outset of the COVID-19 pandemic, the federal government moved quickly to ensure hospitals and health systems were able to leverage telehealth services to respond efficiently and effectively to a wave of unprecedented need. These actions included the Centers for Medicare & Medicaid Services (CMS) waiving certain regulatory requirements and Congress providing significant legislative support to ensure hospitals and health systems could rapidly deploy virtual services.</p><h2>AHA Take</h2><p>The telehealth flexibilities granted resulted in significant benefits to patient care and are needed now more than ever to ensure patients’ continued access to high-quality care. Currently, there is a patchwork of temporary waivers for telehealth services that, barring further action, will expire in March 2025. If this occurs, we risk a telehealth “cliff” that would negatively impact patient access in all communities.</p><p>Recognizing both the immediate and potential long-term benefits of telehealth, we urge Congress, CMS and other executive agencies to take action to make critical telehealth flexibilities permanent.</p><h3>Statutory Waivers</h3><p>The American Relief Act passed at the end of 2024 extended many telehealth waivers for three months. These will expire on March 31, 2025, absent congressional action.</p> table, th, td { border: 1px solid; } th { background-color: #002855; color: white; } <table><thead><tr><th>Topic Area</th><th>Pre-pandemic Permanent Statute</th><th>Waiver</th></tr></thead><tbody><tr></tr><tr><td>Eligible Geographic and Originating Sites</td><td>Patients had to be located in a rural area or health provider shortage area and had to be physically located in a specific setting (e.g., physician’s office) to participate in a telemedicine visit.</td><td>Patients can be in any geographic area (rural or metropolitan) and in any setting, including the beneficiary’s home, at the time of a telehealth visit.</td></tr><tr><td>Audio-only Services</td><td>All telehealth visits had to be performed using real-time audio-visual telecommunications technology, with limited exceptions.</td><td>Allows for expansion of audio-only services for evaluation and management visits and other specified services.</td></tr><tr><td>Eligible Provider Types</td><td>There were limitations on the types of providers who could perform telehealth services.</td><td>Additional providers are allowed to perform telehealth services, including Physical Therapists, Occupational Therapists, Speech-Language Pathologists and Audiologists.</td></tr><tr><td>Eligible Distant/ Provider Sites</td><td>Providers at Federal Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) could not provide telehealth services to patients in other locations.</td><td>FQHCs and RHCs are allowed to serve as distant sites for telehealth services.</td></tr><tr><td>Tele-behavioral Health Visits</td><td>Patients had to receive an in-person evaluation six months before initiating tele-behavioral health treatment and also needed an in-person visit annually thereafter.</td><td>In-person evaluation is not required prior to initiating tele-behavioral health treatment.</td></tr></tbody></table><h3>Regulatory Waivers</h3><p>CMS has issued temporary telehealth waivers, that without further action, will expire on Dec. 31, 2025, without intervention.</p><table><thead><tr><th>Topic Area</th><th>Pre-pandemic Permanent Regulation</th><th>Waiver</th></tr></thead><tbody><tr><td>Virtual Supervision</td><td>Clinical supervision of telehealth required immediate in-person availability of the supervising practitioner.</td><td>CMS allows clinical supervision of telehealth diagnostic tests, physicians’ services and some hospital outpatient services to be met through virtual presence using real-time audio/video technology.</td></tr><tr><td>Virtual Supervision of Residents in Teaching Settings</td><td>Teaching physicians could meet requirements for supervising key or critical portions of resident services through virtual presence instead of physically in person, but only for services furnished in residency training sites in non-Metropolitan Service Areas (non-MSAs).</td><td>Flexibilities for virtual supervision of residents were extended to include MSAs, as well as non-MSAs.</td></tr><tr><td>Virtual Supervision of Cardiac and Pulmonary Rehab Services</td><td>Clinical supervision of cardiac rehab, intensive cardiac rehab, and pulmonary rehab services required immediate in-person availability of the supervising practitioner.</td><td>CMS allows clinical supervision of pulmonary and cardiac rehabilitation to be met through virtual presence using real-time audio/video technology.</td></tr><tr><td>Reporting of Provider Home Address</td><td>Providers who administer telehealth services from their home were required to report their home address on enrollment, billing and claims forms.</td><td>Providers are not required to report home addresses on enrollment, billing and claims forms.</td></tr><tr><td>Payment for Virtual Outpatient Therapy Services</td><td>CMS restricted the ability to bill for telehealth therapy services.</td><td>CMS allows institutional providers to provide therapy services, including outpatient physical therapy, occupational therapy, and speech language pathology via telehealth to patients in their homes.</td></tr></tbody></table><p>DEA also issued temporary waivers regarding prescribing of controlled substances. Without action, these waivers will expire in 2025.</p><table><thead><tr><th>Topic Area</th><th>Pre-pandemic Permanent Regulation</th><th>Waiver</th></tr></thead><tbody><tr><td>In-person Visit Requirements for Prescribing of Controlled Substances</td><td>Prior to prescribing controlled substances, the prescribing practitioner was required to conduct one in-person evaluation of the patient prior to prescribing. This could be waived through a special registration process per statute, but DEA has not finalized a regulation on what this special registration process would entail.</td><td>The in-person evaluation requirement is temporarily waived. (Note: we recommend creation of a special registration process to waive the in-person visit requirement.)</td></tr></tbody></table><h2>Take Action</h2><p>The AHA urges Congress, CMS and the DEA to permanently adopt telehealth policies.</p><h2>Other Resources</h2><ul><li><a href="/news/perspective/2024-10-18-taking-action-extend-telehealth-and-hospital-home-programs">Taking Action to Extend Telehealth and Hospital-at-home Programs</a></li><li><a href="/lettercomment/2024-03-20-aha-urges-cms-remove-telehealth-provider-home-address-reporting-requirements">CMS Urged to Remove Telehealth Provider Home Address Reporting Requirements</a></li><li><a href="/lettercomment/2024-09-09-aha-comments-cms-physician-fee-schedule-cy-2025-proposed-rule">AHA Comments on CMS Physician Fee Schedule CY 2025 Proposed Rule</a></li><li><a href="/news/headline/2024-04-10-aha-urges-congress-make-telehealth-flexibilities-permanent">AHA Urges Congress to Make Telehealth Flexibilities Permanent</a></li><li><a href="/2024-08-12-aha-comments-340b-drug-pricing-program-irf-payments-physician-fee-schedule-and-telehealth">AHA Comments on 340B Drug Pricing Program, IRF Payments, Physician Fee Schedule and Telehealth</a></li><li><a href="/2023-10-10-aha-letter-support-senate-connect-health-act-2023-s-2016">AHA Letter of Support for Senate CONNECT Health Act of 2023 (S. 2016)</a></li><li><a href="/lettercomment/2023-01-30-ahas-feedback-senate-re-connect-act">AHA’s Feedback to the Senate Re: The CONNECT Act</a></li><li><a href="/lettercomment/2023-12-12-aha-comments-support-patients-and-communities-reauthorization-act">AHA Comments on the SUPPORT for Patients and Communities Reauthorization Act</a></li><li><a href="/lettercomment/2022-12-01-aha-letter-dea-regarding-request-release-special-registration-telemedicine-regulation">AHA Letter to DEA Regarding Request for Release of Special Registration for Telemedicine Regulation</a></li></ul></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/05/fact-sheet-telehealth-waivers.pdf" title="Telehealth Waivers"><img src="/sites/default/files/inline-images/Page-1-Fact-Sheet-Telehealth%20Waivers-20250207.png" data-entity-uuid="39b6ad7e-bed7-4dac-b0c8-ef00ea98859d" data-entity-type="file" alt="Fact Sheet: Telehealth Waivers page 1." width="695" height="900"></a></p></div></div></div> h2 { color: #003087; } h3 { color: #9d2235; } Fri, 07 Feb 2025 12:45:00 -0600 Fact Sheets /fact-sheets/2025-02-07-fact-sheet-2025-telehealth-advocacy-agenda <div class="container"><div class="row"><div class="col-md-8"><p>Telehealth has long provided increased access to care and convenience for patients, but waivers allowed broader portions of the population to experience the benefits of virtual care. The increased availability of telehealth services has transformed care delivery, expanded access for millions of Americans and increased convenience in caring for patients.</p><p>Given current health care challenges, including major clinician shortages, telehealth holds tremendous potential to leverage geographically dispersed provider capacity to support patient demand.</p><p>The AHA continues to work with Congress and the administration to enact telehealth reform to help providers and beneficiaries be able to utilize these services on a permanent basis. Given the pending expiration of several waivers, we urge Congress to act to extend this critical lifeline for treatment and work towards a permanent pathway for provision of telehealth services.</p><p>Below are the AHA’s telehealth advocacy priorities for 2025.</p><h2>Permanently Adopting Enhanced Telehealth Policies</h2><ul><li>Permanently eliminate originating and geographic site restrictions allowing telehealth visits to occur at any site which the patient is located, including urban areas and the patient’s home.</li><li>Permanently eliminate in-person visit requirements for tele-behavioral health, which would ensure that patients do not need an in-person visit before initiating virtual treatment.</li><li>Permanently remove distant site restrictions on federally-qualified health centers and rural health clinics, which would ensure that they can continue to provide telehealth services.</li><li>Permanently continue payment and coverage for audio-only telehealth services.</li><li>Permanently expand eligible telehealth provider types to include physical therapists, occupational therapists, speech-language pathologists and audiologists.</li></ul><h2>Expanding Telehealth Workforce</h2><ul><li>Permanently allow for virtual supervision by modifying the definition of direct supervision to include virtual presence of the supervising clinician.</li><li>Permanently allow for virtual supervision of residents across geographies to include both Metropolitan Service Areas and Non-Metropolitan Service Areas.</li><li>Permanently allow for virtual supervision for certain hospital outpatient services to include cardiac rehabilitation, intensive cardiac rehabilitation and pulmonary rehabilitation services.</li><li>Permanently remove the requirement for telehealth providers to report their home address on enrollment and claims forms when administering services from their home.</li><li>Remove unnecessary barriers to cross-state licensure.</li></ul><h2>Ensuring Fair and Adequate Telehealth Reimbursement</h2><ul><li>Permanently cover virtual outpatient therapy services, diabetes self-management training, and medical nutrition therapy services to patients’ homes.</li><li>Expand eligible virtual services beyond professional services.</li></ul><h2>Supporting Telehealth for Rural and Underserved Areas</h2><ul><li>Permanently remove the in-person visit requirements for prescribing of controlled substances through the creation of a new, streamlined Special Registration Process for Telemedicine</li><li>Expand cross-agency collaboration on digital infrastructure (to include broadband) and digital literacy initiatives.</li></ul></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/05/fact-sheet-2024-telehealth-advocacy-agenda.pdf" target="_blank" title="Click here to download the Fact Sheet: 2025 Telehealth Advocacy Agenda PDF."><img src="/sites/default/files/inline-images/Page-1-Fact-Sheet-2025-Telehealth-Advocacy-Agenda.png" data-entity-uuid="1e6e57a9-77ad-4e6d-a904-5630cfdfe9a8" data-entity-type="file" alt="Fact Sheet: 2025 Telehealth Advocacy Agenda page 1." width="695" height="900"></a></p></div></div></div> h2 { color: #003087; } Fri, 07 Feb 2025 11:30:00 -0600 Fact Sheets /fact-sheets/2025-02-07-fact-sheet-enhanced-premium-tax-credits <div class="container"><div class="row"><div class="col-md-8"><h2>The Issue</h2><p>The federal government offers enhanced premium tax credits (EPTCs or tax credits) to help some individuals and families purchase insurance on the health insurance marketplaces. Eligibility and tax credit amounts are based on the individual or family’s income level, as well as their access to other forms of comprehensive coverage, e.g., through their employer.</p><p>In 2021, Congress increased and expanded eligibility for the tax credits; however, those policies are scheduled to expire at the end of 2025. These 2021 tax credits have resulted in an additional 10 million people gaining coverage through the health insurance marketplaces while others receiving assistance paying their health insurance costs.<a href="#fn1"><sup>1</sup></a> This has increased access to health care coverage and high quality care for patients and communities served by hospitals, health systems and other providers.</p><h2>AHA Take</h2><p>In support of the health of our patients and communities, as well as the stability of the entire health care system, the AHA urges Congress to extend the enhanced premium tax credits.</p><h2>Why?</h2><ul><li>The tax credits helped millions of Americans purchase affordable commercial health care coverage. <span><strong>The expiration of this policy would effectively be a tax increase of $700 on average for millions of people across the nation.</strong></span></li><li>The expiration of the enhanced tax credits would lead to an increase in the number of uninsured people. There would be a disproportionate impact to those in rural states and those with lower incomes.</li><li>Some states would see higher rates of disruption in coverage and loss of federal tax funds, particularly those that have not expanded Medicaid. Several of these states, such as Texas and Florida, experienced some of the highest enrollment growth in the health insurance marketplaces due to the enhanced tax credits.</li><li>The loss of coverage would put considerable financial stress on hospitals, health systems and other providers, which will face more uncompensated care and bad debt. This, in turn, would make it difficult for them to maintain services in their communities KNG Health Consulting found that <span><strong>allowing the EPTCs to expire would result in a $28 billion reduction in hospital spending over 10 years.</strong></span></li></ul><h2>Background</h2><p>Certain individuals and families are eligible for prospective, monthly tax credits that lower the cost of health insurance marketplace premiums. To be eligible, these individuals or families must:</p><ul><li>Meet certain income thresholds, based on the federal poverty level (FPL).<a href="#fn2"><sup>2</sup></a></li><li>Not be eligible for other comprehensive coverage, including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or affordable employer-sponsored coverage (defined as costing less than 8.5% of household income).<a href="#fn3"><sup>3</sup></a></li><li>Be a U.S. citizen or have proof of legal residency or, as of Jan. 1, 2025, be eligible for Deferred Action for Childhood Arrivals.</li><li>If married, file taxes jointly.</li></ul><p>The amount of tax credit that an individual or family is eligible for is based on household income, as well as the cost of the second-lowest silver plan in the individual’s market. Once an individual or family has been determined eligible and selected their preferred health plan, the tax credit is immediately applied directly to the premium; thus, the enrollee only needs to pay the remaining amount.</p><hr><ol><li id="fn1"><a href="https://www.kff.org/affordable-care-act/issue-brief/a-look-at-aca-coverage-through-the-marketplaces-and-medicaid-expansion-ahead-of-potential-policy-changes">kff.org/affordable-care-act/issue-brief/a-look-at-aca-coverage-through-the-marketplaces-and-medicaid-expansion-ahead-of-potential-policy-changes</a></li><li id="fn2">The income used to calculate the EPTCs is an estimate by the applicant based on what they expect their household income to be in the coming year. When filing taxes at the end of the year, they may receive additional tax credits if their income was lower than expected. Alternatively, they may have to repay some of their tax credit if their income was higher than expected.</li><li id="fn3">For employer-sponsored coverage to be considered affordable, it must meet a minimum value requirement, and the annual premium must be equal to or less than 9.02% of the individual’s household income.</li></ol></div><div class="col-md-4"><p><a href="/system/files/media/file/2025/02/Fact-Sheet-Enhanced-Premium-Tax-Credits-20250207.pdf" target="_blank" title="Click here to download the Fact Sheet: Enhanced Premium Tax Credits PDF."><img src="/sites/default/files/inline-images/Page-1-Fact-Sheet-Enhanced-Premium-Tax-Credits-20250228.png" data-entity-uuid="13585e49-ae34-4b87-ad0a-5fca1e589d6f" data-entity-type="file" alt="Fact Sheet: Enhanced Premium Tax Credits page 1." width="695" height="900"></a></p></div></div></div> h2 { color: #003087; } Fri, 07 Feb 2025 10:38:20 -0600 Fact Sheets /fact-sheets/2025-02-07-fact-sheet-medicaid <div class="container"><div class="row"><div class="col-md-8"><h2>The Issue</h2><p>The Medicaid program is the largest single source of health care coverage in the United States, covering nearly half of all children, over 40% of births (including nearly 50% of births in rural communities), many low-income elderly and disabled individuals, and working adults in low-wage jobs that do not offer affordable coverage. Congress is currently considering policy options that could collectively reduce federal spending for the Medicaid program by trillions of dollars over the next 10 years. These options include proposals to directly reduce federal spending on the program and limit states’ ability to generate funding for the state share of the costs.</p><h2>AHA Take</h2><p>Even a small portion of the proposed reductions could have wide-ranging negative consequences for the health and well-being of both Medicaid enrollees and the broader health care system. <span><strong>AHA urges Congress to reject reductions to the Medicaid program that would not only strip access to health care from some of the most vulnerable populations but also destabilize hospitals and health systems, leading to a loss of services that would impact patients and communities nationwide.</strong></span></p><h2>Why?</h2> h2 { color: #003087; } table, th, td { border: 1px solid; } th { background-color: #003087; color: white; } <ul><li>Medicaid provides critical health coverage to a wide variety of people in every community across the nation. This coverage helps ensure patients can receive the medical services needed to live healthier and more productive lives.</li><li>Medicaid covers over 40% of births in the U.S., including nearly 50% of births in rural communities.<a href="#fn1"><sup>1</sup></a> It is also a vital source of prenatal and postpartum care for women across the country.</li><li>State Medicaid programs pay hospitals less than the cost hospitals incur to provide care to Medicaid patients. In 2023, the difference between Medicaid payments and costs, known as “Medicaid shortfall,” was $27.5 billion.2</li><li>Medicaid is an important source of support for the health care system. The impact of cuts to Medicaid would not be limited to just Medicaid beneficiaries. It would stress the availability of health care services for everyone. Today, hospitals that serve disproportionately high rates of Medicaid and other public-payer patients routinely operate with negative margins and are often forced to terminate service lines or close entirely. Reductions in federal support for Medicaid would exacerbate these pressures, which could strip essential health care services for an entire community.</li><li>Medicaid is one of the most cost-efficient forms of coverage. It has lower total and per capita costs than all other major health programs, including Medicare and private health insurance.</li><li>Most of the spending on Medicaid is for disabled and elderly individuals. States could not absorb the magnitude of the proposed cuts by solely reducing enrollment or services for working-age adults — the disabled and elderly populations would also be negatively impacted.</li></ul><h2>Background</h2><p>Medicaid is a joint federal-state program that covers primary and acute care services, as well as long-term care services and supports, for low-income populations, including children and their families, seniors, disabled individuals and adults, many of whom work. Medicaid provides health care coverage to one in five Americans — more than 70 million people — including 40% of all children and 60% of all nursing home residents.<a href="#fn3""><sup>3</sup></a></p><p>The federal and state governments jointly finance Medicaid. The federal government sets the basic framework for covering certain mandatory populations and benefits, as well as regulates the delivery of health care services and reimbursement. The federal government also pays a share of states’ Medicaid expenses based on the state’s federal medical assistance percentage (FMAP), which varies from a federal floor of 50% up to 76% depending on a state’s per capita income relative to the national average. States, in turn, have latitude in the design and administration of their programs. In addition, states can use waiver and demonstration authorities approved by the Centers for Medicare & Medicaid Services (CMS) to test opportunities for innovation by operating their Medicaid programs outside of certain federal rules.</p><h2>Who Is Covered Through Medicaid</h2><p>The federal government sets the minimum eligibility standards, and states may expand eligibility within federal limits. Medicaid eligibility is generally determined based on an individual’s age, health condition and income level (including, in some cases, an asset test). Approximately 42% of Medicaid beneficiaries are adults, 36% are children, 10% are disabled, and 10% are age 65 or older.<a href="#fn4"><sup>4</sup></a> Individuals who are eligible based on disability or age make up a small share of beneficiaries overall but account for over half of all Medicaid spending.</p><h2>Selected Examples of Mandatory and Optional Medicaid Eligibility Categories</h2><p>States are required to cover certain populations, while others are classified as optional. Despite being eligible for coverage at state option, many of these populations are among the most vulnerable. Yet, when states face budget shortfalls, they often look to optional groups for benefit reductions.</p><table><thead><tr><th>Mandatory</th><th>Optional</th></tr></thead><tbody><tr><td><ul><li>Children through age 18 in families with incomes at or below 133% Federal Poverty Level (FPL)</li></ul></td><td><ul><li>Infants in families with incomes above 185% FPL</li><li>Children receiving certain state adoption assistance</li></ul></td></tr><tr><td><ul><li>Pregnant women with incomes at or below 133% FPL</li></ul></td><td><ul><li>Pregnant women between 133-185% FPL</li></ul></td></tr><tr><td><ul><li>Certain parents or caretakers with very low incomes</li></ul></td><td><ul><li>Adults (parents or childless) with incomes at or below 133% FPL</li></ul></td></tr><tr><td><ul><li>Most seniors and people with disabilities who receive cash assistance through Supplemental Security Income</li></ul></td><td><ul><li>Seniors with incomes above 135% FPL</li><li>Nursing home residents with incomes above 200% FPL</li><li>Home and Community Based Services Waiver Enrollees</li></ul></td></tr></tbody></table><p><strong>Note:</strong> FPL is defined as $15,060 for an individual in 2024.</p><div class="row"><div class="col-md-6"><p>Medicaid covers millions of people across the U.S., reaching individuals in all regions, from rural communities to urban centers. In addition to children, pregnant women, and low-income elderly and disabled individuals, Medicaid covers working adults in low-wage jobs. This opportunity for health care coverage provides a valuable resource for businesses that employ low-wage workers.</p></div><div class="col-md-6"><p><img src="/sites/default/files/inline-images/Health-Insurance-Coverage-of-the-Total-Population-Medicaid-2023-map.png" data-entity-uuid="dabda1f0-7475-4fa9-9f3f-4b0099c89c4c" data-entity-type="file" alt="Health Insurance Coverage of the Total Population: Medicaid, 2023, map." width="451" height="345"></p></div></div><h2>What Services Medicaid Covers</h2><p>States are required to provide coverage for certain benefits and have the option of covering additional services. This results in significant variation across states in terms of what care Medicaid covers. In addition, Medicaid is statutorily prohibited from paying for services in an institute for mental disease for adults aged 21 through 64, and federal law prohibits the use of federal funds to pay for abortion services.</p><table><thead><tr><th>Mandatory</th><th>Optional</th></tr></thead><tbody><tr><td><ul><li>Inpatient hospital services</li></ul></td><td><ul><li>Prescription drug coverage</li></ul></td></tr><tr><td><ul><li>Outpatient hospital services</li></ul></td><td><ul><li>Dental services</li></ul></td></tr><tr><td><ul><li>Physician services</li></ul></td><td><ul><li>Physical and occupational therapy</li></ul></td></tr><tr><td><ul><li>Lab and x-ray services</li></ul></td><td><ul><li>Speech and hearing services</li></ul></td></tr><tr><td><ul><li>Rural and federally qualified health clinic services</li></ul></td><td><ul><li>Eyeglasses</li></ul></td></tr><tr><td><ul><li>Nurse midwife services</li></ul></td><td><ul><li>Prosthetics</li></ul></td></tr><tr><td><ul><li>Nursing facility services</li></ul></td><td><ul><li>Clinic services</li></ul></td></tr><tr><td><ul><li>Home health care services for people qualified for nursing facility services</li></ul></td><td><ul><li>Hospice</li></ul></td></tr><tr><td><ul><li>Smoking cessation services for pregnant women</li></ul></td><td><ul><li>Inpatient psychiatric services for people under 21 years old</li></ul></td></tr><tr><td><ul><li>Free-standing birth center services</li></ul></td></tr><tr><td><ul><li>Family planning services</li></ul></td></tr></tbody></table><h2>Payment</h2><div class="row"><div class="col-md-6"><p>States have broad authority to design reimbursement methods for providers, subject to federal approval. State Medicaid agencies pay providers for services and may make additional supplemental payments. Medicaid payment rates are low relative to other payers.</p><p>Many states choose to provide Medicaid coverage by contracting with private Medicaid managed care organizations (MCOs). Medicaid MCOs are often paid on a capitated basis, and states must submit capitation payment rates annually for federal approval. About 74% of Medicaid beneficiaries are enrolled in Medicaid managed care.</p></div><div class="col-md-6"><p><img src="/sites/default/files/inline-images/Total-Medicaid-MCO-Enrollment-Comprehensive-Risk-Based-Managed-Care-Enrollees-2022-map.png" data-entity-uuid="23f989b2-abf6-4df8-8df4-8ca47bc3e90f" data-entity-type="file" alt="Total Medicaid MCO Enrollment: Comprehensive Risk-Based Managed Care Enrollees, 2022" width="454" height="386"></p></div></div><hr><ol><li id="fn1">AHA analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), National Vital Statistics System (NVSS), Natality data on the CDC WONDER Online Database (2023).</li><li id="fn2">AHA analysis.</li><li id="fn3"><a href="/medicaid">www.aha.org/medicaid</a></li><li id="fn4"><a href="https://www.macpac.gov/publication/medicaid-enrollment-by-state-eligibility-group-and-dually-eligible-status/" target="_blank">https://www.macpac.gov/publication/medicaid-enrollment-by-state-eligibility-group-and-dually-eligible-status/</a></li></ol></div><div class="col-md-4"><a href="/system/files/media/file/2025/02/Fact-Sheet-Medicaid-20250204.pdf"><img src="/sites/default/files/inline-images/Page-1-Fact-Sheet-Medicaid-20250204.png" data-entity-uuid="2efdcafd-41ba-4a88-a062-e5426351fb8b" data-entity-type="file" alt="Fact Sheet: Medicaid page 1." width="695" height="900"></a></div></div></div> h2 { color: #003087; } Fri, 07 Feb 2025 10:00:02 -0600 Fact Sheets