Key bills pass House & Senate, now eligible to be signed into law
The Georgia House of Representatives and Senate passed a number of health care bills this week. Having passed both chambers, these measures are now eligible to be signed into law by Gov. Nathan Deal.
The House passed…
S.B. 96 by Sen. Ben Watson (R-Savannah), which would allow physician assistants, nurse practitioners, and registered nurses to pronounce an organ donor’s death in hospice settings. MAG is neutral on this legislation.  
S.B. 47 by Sen. Chuck Hufstetler (R-Rome), which would allow a visiting sports team’s physicians and athletic trainers to provide care in Georgia without the need to be licensed in the state. MAG supports this measure. 
S.B. 103 by Sen. Jeff Mullis (R-Chickamauga), which would give the Georgia Department of Community Health (DCH) the authority to 1) investigate pharmacy benefit managers (PBM) and 2) prevent PBM/insurers from requiring the use of a mail-order pharmacy or from requiring an insured patient to pay a different copay for using his/her pharmacy of choice and 3) prohibit PBM from prohibiting pharmacies from providing information about prescription drugs, offering delivery services, or advocating on behalf of an insured to the PBM. MAG supports this legislation.
Meanwhile, the Senate passed…
H.B. 157 by Rep. Trey Kelley (R-Cedartown), which would repeal a bill that was signed into law in 2016 that limits a physician’s ability to advertise and publicize their medical specialty certification to specific certification boards. MAG policy supports the current law, and MAG will continue to develop and promote legislation that will protect patients from deceptive advertising. 
H.B. 276 by Rep. David Knight (R-Griffin), which would allow the commissioner of the Georgia Department of Community Health to promulgate rules that are related to the oversight of pharmacy benefit managers (PBM) and investigate PBM for any violations. This bill would prevent a PBM/insurer from requiring the use of a mail-order pharmacy or from requiring a covered individual to pay a different copay for using his/her pharmacy of choice, it would prohibit PBM from prohibiting pharmacies from disseminating information about prescription drug alternatives or delivery services, and it would place other limits on PBM that are related to “financial maneuvers.” MAG supports this legislation.
In another important development, Speaker David Ralston’s FY 2018 state budget (H.B. 44) will be going to a conference committee to resolve the differences between the House and Senate. 
House amends/passes interstate compact bill – which now goes back to Senate
By a vote of 161-9, the Georgia House passed a bill (S.B. 109) by Sen. Michael Williams (R-Cumming) that would establish an interstate licensure compact to allow EMS personnel to travel from one participating state to another without having to obtain a license in the other states under certain circumstances (e.g., transporting a patient).
The measure was also amended to include the provisions of the ‘Nurse Licensure Compact’ (S.B. 166 by Sen. Renee Unterman) – which would allow registered nurses and licensed practical nurses to be licensed in more than one state, though the scope of the care they are allowed to provide would be determined by the state where the patient receives the care.
MAG is neutral on the legislation, which will now go back to the Senate – which must vote to agree or disagree to the changes that were made in the House.
MAG remains focused on out-of-network ER billing legislation 
Sen. Michael Williams (R-Cumming) introduced S.B. 277, which is based on model legislation that MAG and other physicians’ advocacy organizations developed to address the “surprise insurance coverage gap” and end the need for balance billing. The bill would require physicians who deliver care in an ER setting on an out-of-network basis be paid at the 80th percentile of the FAIR Health (a national, independent, non-profit corporation) database. 
MAG Government Relations Director Derek Norton explains that, “S.B. 277 will not be eligible to pass during this year’s legislative session, but we wanted to make sure that this solution for the out-of-network billing problem was in play and available as a reference point.”
Norton also stresses that MAG is still working with lawmakers and the other aforementioned physicians’ advocacy organizations on another bill, S.B. 8, that is designed to address out-of-network billing in ER settings that remains in play in this year’s session. S.B. 8 is in the House Insurance Committee. 
MAG opposing APRN/prescriptive authority bill 
The House Health and Human Services (HHS) Committee passed a bill (S.B. 242) by Sen. Renee Unterman (R-Buford) that would increase the number of advanced practice registered nurses (APRN) that have prescriptive authority that a physician can delegate their authority to in certain circumstances. The bill originally called for the number to be increased from four to 10 – though no more than four at any single point in time. The House HHS reduced the maximum number from 10 to eight. MAG supports the current limit of four, and it is opposing any increase.   
The version of this bill that passed the Senate included a provision that would require the APRN to provide the patient with the supervising physician’s name and to transmit the patient’s record to their primary care physician. 
MAG also offered an amendment that would have increased the chart review requirement from 10 percent to 20 percent, but it failed to pass the House HHS Committee. 
MAG testified to oppose this legislation, which the full House is expected vote on next Monday, March 20. 
Senate HHS passes three key health care bills
The Georgia Senate Health and Human Services (HHS) Committee passed a bill (H.B. 165) by Rep. Betty Price, M.D. (R-Roswell) that would prevent the Medical Practice Act from being used or interpreted to require Maintenance of Certification for licensure, employment in a state hospital, insurance panels, or medical malpractice insurance. This is one of MAG’s legislative priorities. The bill will now move into the Senate Rules Committee. 
The Senate HHS also passed an omnibus bill (H.B. 249) by Rep. Kevin Tanner (R-Dawsonville) that is designed to reduce opioid abuse in the state. This measure would 1) require health care providers and others to report instances of neonatal abstinence syndrome to the Georgia Department of Public Health and 2) codify Gov. Nathan Deal’s executive order to make naloxone available on an over-the-counter basis in the state and 3) require dispensers to update the state’s Prescription Drug Monitoring Program (PDMP) every 24 hours. 
The committee considered an amendment that would have required physicians to provide their patients with written information about addiction and disposal (i.e., for unneeded drugs) every time they prescribe an opioid, but MAG was able to convince lawmakers to allow physicians to deliver the information to their patients on a verbal basis. 
Under H.B. 249, physicians would have to check the PDMP every time they write a prescription for Schedule II (paragraph 1 and 2) drugs and for benzodiazepines, several exceptions notwithstanding (e.g., prescriptions for three days or for 26 pills or less or for prescriptions for 10 days or less after surgery). As for benzodiazepines, prescribers would only have to check the PDMP when they write the patient’s initial prescription and every 90 days thereafter. MAG has worked with Rep. Tanner and other lawmakers throughout session to ensure the best, most reasonable outcome for physicians and their patients. H.B. 249 will now move into the Senate Rules Committee. 
Finally, the Senate HHS passed a bill (H.B. 427) – the ‘Physicians and Health Care Practitioners for Rural Areas Assistance Act’ – by Rep. Mark Newton (R-Augusta) that would add dentists, physician assistants, and advanced practice registered nurses to the list of practitioners who are eligible for the service cancelable loan program that is administered by the Georgia Board for Physician Workforce. These funds are already built into the budget for FY 2018. MAG is watching this legislation, which has moved into the Senate Rules Committee.
The week’s other legislative highlights
The House Special Rules Committee passed a resolution (H.R. 282) by Rep. John Carson (R-Marietta) that would create a House study committee on distracted driving – keeping in mind that MAG has been promoting a bill (H.B. 163) that would require drivers who make phone calls while operating a motor vehicle to do so on a hands-free basis as one of its patient safety priorities during this year’s legislative session. H.B. 163 did not pass the House by the end of the March 3 ‘Crossover Day,’ but MAG has asked to be part of any H.R. 282 study committee – which would meet this summer. 
The House Insurance Committee passed two bills this week, including a measure (S.B. 200) by Chuck Hufstetler (R-Rome) that would require insurers to cover prescriptions that are for less than 30 days at a “prorated daily cost-sharing rate” when it is in the best interest of the patient or when it is for the purpose of synchronizing the insured patient's medications for chronic conditions. MAG has not taken a position on this legislation, which is now in the House Rules Committee. 
The House Insurance Committee also passed a measure (S.B. 206) by Sen. P. K. Martin (R-Lawrenceville) that would require health insurers to cover billed charges of up to one hearing aid per impaired ear not to exceed $3,000 per hearing aid every 48 months for covered patients who are 18 or younger. MAG is watching this legislation, which is expected to receive a vote by the full House next Monday, March 20. 
The House Judiciary Non-Civil Setzler Subcommittee passed a bill (S.B. 125) by Sen. Rick Jeffares (R-McDonough) that would allow physician assistants (PA) and advanced practice registered nurses (APRN) to prescribe hydrocodone pursuant to protocol agreements. Under this bill, they would be limited to writing prescriptions for five days and the lesser or 30 pills or 300 milligrams for adults (i.e., 18 or older). For patients who are under 18, PA and APRN would only be able to write prescriptions for five days and the lesser of 30 pills or 100 milligrams. PA or APRN who want to write hydrocodone prescriptions would be required to complete three hours of continuing education in the “appropriate ordering and use of Schedule II controlled substances” every two years. APRN would also be required to have a minimum of 36 months of clinical experience after they receive their APRN designation to prescribe hydrocodone. Finally, the Georgia Composite Medical Board would have jurisdiction over APRN who prescribe hydrocodone. MAG supported the addition of these limitations and requirements. S.B. 125 will now move into full House Judiciary Non-Civil Committee.
The House Judiciary Committee also passed an amended version of S.B. 16, which is a bill that was introduced by Sen. Ben Watson, M.D. (R-Savannah) to modify the state’s medical cannabis law. The original version of S.B. 16 would have reduced the amount of THC that would be allowable in the cannabinoid oil and it would have added of autism to the list of qualifying conditions. The new House/Senate compromise would leave the THC at the current 5.0 percent level and it would add six qualifying conditions, including 1) "severe" autism for people who are under the age of 18 and 2) autism for people who are 18 or older and 3) severe or end-stage cases of Alzheimer's disease and 4) AIDS or peripheral neuropathy and 5) severe Tourette's syndrome and 6) any case of epidermolysis bullosa. S.B. 16 would also make the low THC cannabinoid oil available to people who are in hospice programs. MAG policy does not support expanding the number of conditions that are covered by state law. This bill now moves to the House Rules Committee. 
Finally, the House Judiciary Non-Civil Committee passed a bill (S.B. 121) by Sen. Butch Miller (R-Gainesville) that would codify Gov. Nathan Deal’s executive order to make naloxone available on an over-the-counter basis in the state. MAG supports this legislation, which will now go to the House Rules Committee.
Thanking this week’s ‘Doctor of the Day’ volunteers
MAG is thanking and applauding its ‘Doctor of the Day’ volunteers for the week of March 13, which include…
Kamesha Harbison, M.D.
Douglas G. Nuelle, M.D.
LaJune B. Oliver, M.D.
Jonathan G. Ownby, M.D.
Michelle R. Zeanah, M.D.
MAG Doctor of the Day volunteers work in the Medical Aid Station at the State Capitol, where they provide free minor medical care to legislators and their staff members. 
Go to www.mag.org/advocacy/take-action/dod for additional information on the MAG ‘Doctor of the Day’ program, including logistical details and FAQ.
Reserve a room for MAG’s summer seminar for $189/night
The Medical Association of Georgia (MAG) is encouraging its member physicians to reserve a room for MAG’s 2017 ‘Legislative Education Seminar,’ which will take place at the Brasstown Valley Resort in Young Harris on the evening of Friday, June 23 and Saturday, June 24.
MAG members can call 800.201.3205 and ask for the “Medical Association of Georgia” discount to reserve a room for $189 per night. The discount will be available until May 17 or until MAG’s block of rooms sells out. 
More than 25 state legislators attended this event in 2016.
Monitor www.mag.org for additional details, and contact Derek Norton at dnorton@mag.org or 678.303.9280 with any questions.
AHCA: Summary, budget estimates & next steps
The following summary was written by Julius Hobson, Cybil Roehrenbeck and Sidney Welch with Polsinelli PC.
On March 6, 2017, House Republicans released proposed legislation referred to as the American Health Care Act (AHCA) to replace the Patient Protection and Affordable Care Act (ACA), which was signed into law in 2010 under the Obama administration. The House Energy and Commerce Committee and House Ways and Means Committee then marked up their portions of the bill, including consideration of amendments offered.¹  
Procedurally, the proposed legislation will go to the House Budget Committee and then the Rules Committee. If the bill passes the House, it will go to the Senate where, under budget reconciliation rules, the only changes that can be made will be those which impact the budget. Passage by the Senate will require only a simple majority vote. Once approved by the Senate, it would be signed by President Trump. If, however, the president vetoes the bill, Congress could override the veto with a two-thirds vote of both houses.
Referred to as a “starting point” by Health and Human Services (HHS) Secretary Tom Price, M.D., the American Hospital Association, the American Medical Association, America’s Health Insurance Plans, and the American Association of Retired Persons are just some of the organizations that have opposed the plan. More opposition and changes are anticipated in light of the Congressional Budget Office (CBO) cost estimates, released March 13, 2017², which estimates that nearly 24 million individuals will lose their health insurance coverage if the ACA is repealed and the AHCA is enacted in its current form. 
AHCA Summary 
As proposed, the AHCA calls for the following changes at the federal level…
– Eliminate individual and employer mandates. Beginning in 2016, individual and employer coverage mandate penalties would be reduced to $0 and would, beginning in 2019, be replaced with mandatory penalties for failure to maintain coverage as the incentive to enroll in coverage. Insurers would assess a penalty on any individual who experienced 63 or more continuous days without coverage during a 12-month look-back period, the “Continuous Health Insurance Coverage Initiative.”
– Replace health insurance subsidies with refundable tax credits. In lieu of the ACA’s subsidies to help qualifying individuals pay for insurance premiums, the proposed bill would make available age-based, advanced, refundable tax credits to individuals without another source of coverage starting in 2020. The value of the tax credit would start at $2,000 annually for individuals under age 30 and increase with each decade of age to a maximum of $4,000 annually for individuals over age 60. Families claiming tax credits for multiple family members would be capped at a maximum tax credit of $14,000 annually. The amounts would be updated by CPI+1 annually.
– Delay “Cadillac Tax.” The bill would delay the imposition of the “Cadillac Tax” from high cost employer plans from 2020 to 2025.
– Repeal certain other taxes. The bill would repeal the ACA’s “Premium Tax Credit,” which was designed to help individuals and families with low or moderate income afford health insurance purchased through the marketplace, effective in 2020. This includes a 3.8% tax on investment income and a 0.9% tax at certain income levels ($200,000 for individuals and $250,000 for families). The bill would also repeal taxes on insurers, prescription drugs, indoor tanning, and medical device manufacturers.
– Increase premium age differentials. Allows insurers to charge older customers up to five times the amount the charge younger customers instead of three times the amount.
– Expand health savings accounts (HSA) contributions. The proposal would increase the maximum amount an individual or family could contribute to their HSA (from $3,400 to $6,500 for individuals and from $6,750 to $13,100 for families).
– Defund certain organizations. The bill would bar certain nonprofit organizations that provide abortions from receiving Medicaid reimbursement.
At the state level – the largest savings projected by the CBO at an estimated $880 billion – the bill would…
– Revise Medicaid expansion. The bill would phase out Medicaid expansion by granting federal funds to states on a capped, per-capita basis beginning in 2020 in lieu of matching federal funds to states for anyone who qualifies. It would give states the ability to choose to expand Medicaid eligibility with reduced federal support for additional eligible patients instead of the ACA’s blanket expansion to 138% of poverty level. Further, it would end presumptive eligibility except for children, pregnant women, and breast and cervical patients. It would also provide that cuts to disproportionate share hospitals would not apply in non-expansion states and would be enforced in expansion states until 2020, at which time they would be repealed. It would provide $10 billion to non-expansion states for safety net funding, too.
– Repeal essential health benefits. Beginning in 2020, the federal essential health benefit requirements would be repealed for certain limited benefit plans and states would have authority to set any minimum benefit standards and the AV standards for metal level plans would be repealed allowing states to approve more flexible benefit designs.
– Create a “Patient and State Stability Fund” to stabilize the marketplace. The proposal would create a $100 billion fund for states to use for various purposes, including forming high risk pools, out-of-pocket costs, access to preventive services, and establishing reinsurance programs. 
The following ACA provisions would remain the same…
– Coverage for pre-existing health conditions
– Coverage for dependents until age 26
– Prohibition against annual and lifetime limits on individual coverage
Notably absent from the bill are the following, which may be addressed in other legislation or by executive order…
– Medicare reform
– Drug price increases
– Tort reform
Budget Estimates
CBO estimates that the AHCA would reduce federal deficits by $337 billion over 10 years. This consists of $323 billion in on-budget savings and $13 billion in off-budget savings. The outlays would be reduced by $1.2 trillion over the same period, and revenues would be reduced by $883 billion.
CBO and the Joint Committee on Taxation (JCT) estimate that 14 million more people would be uninsured under the AHCA in 2018. CBO further projects that “following additional changes to subsidies for insurance purchased in the nongroup market and to the Medicaid program, the increase in the number of uninsured people relative to the number under current law would rise to 21 million in 2020 and then to 24 million in 2026.” By 2026, CBO estimates 52 million people would be uninsured, as compared with 28 million who would lack insurance that year under current law.
CBO and JCT estimate that average health insurance premiums in the individual market would be 15 percent to 20 percent higher than under the ACA. This increase is attributed to the elimination of the individual mandate penalties, resulting in fewer healthy people signing up for insurance.
JCT and CBO estimate that the AHCA would result in private sector mandates totaling $156 million in 2017, adjusted annually for inflation. Finally, CBO is uncertain about part of its estimates as it cannot determine “the ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to the changes made by the legislation…”
Next Steps
In accordance with the Congressional Budget and Impoundment Control Act of 1974, the House Budget Committee is scheduled to meet this week to report the reconciliation bill. The Committee’s role is simply to package the two bills from the Energy and Commerce and Ways and Means Committees.
Following the Budget Committee’s action, the House Rules Committee will meet to develop a rule, which would govern floor debate for the AHCA. The Rules Committee may fold bills reported by the Education and the Workforce Committee into the reconciliation package. The House Majority Leadership plans to take the AHCA to the floor next week. Senate Majority Leader Mitch McConnell [R-KY] plans to skip the committee process and take up the House-passed bill.
Note: Medical Association of Georgia (MAG) staff is reviewing the American Health Care Act and will discuss this legislation with MAG’s leadership groups.
Sidney Welch is one of MAG’s endorsed vendors. She is the chair of Health Care Innovation at Polsinelli PC. Welch counsels physicians, physician’s practices, and health care technology clients in transactional, regulatory, administrative law, and litigation matters on a national basis. Go to www.polsinelli.com/ professionals/swelch for additional information. Contact Welch at 404.253.6047 or swelch@polsinelli.com. 
MAG’s 2017 state legislative priorities 
The Medical Association of Georgia’s priorities for the 2017 state legislative session include…
Out-of-Network Billing & Network Adequacy
MAG will 1) support reforms that will require appropriate network adequacy standards for health insurers and 2) call for health insurers to be more transparent in their contracts with physicians’ practices and 3) support legislation that will result in physician payment methodologies that are adequate and sustainable for out-of-network emergency care.  
Medicaid Payment Parity
MAG will be an advocate for the General Assembly to continue to fund the Medicaid parity payment program for all areas of primary care.
Maintenance of Certification (MOC)
MAG will 1) work to ensure that Maintenance of Certification is not a condition of licensure or a condition of hospital credentialing and 2) support efforts that will alleviate the costly and burdensome aspects of MOC for physicians.
Patient Safety
MAG will be an advocate for legislation that improves patient safety.
Contact MAG Government Relations director Derek Norton at dnorton@mag.org or 678.303.9280 with questions related to MAG’s legislative priorities for 2017.
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