Implementing Health Reform. On October 23, the House of Representatives passed with a nearly party-line vote of 240 to 189 a budget reconciliation act intended to repeal key provisions of the Affordable Care Act. The terms and import of this bill were discussed in an earlier post.
Since that post was written, the House has dropped the provision of the bill repealing the Independent Payment Advisory Board (IPAB) because of concerns that it could not be adopted by the Senate because of procedural issues. The reconciliation bill now goes to the Senate, where it faces an uncertain future because of reported concerns of Republicans who believe it goes too far or not far enough. If it passes the Senate it will certainly be vetoed by President Obama.
Healthcare.gov Improvements For 2016
On October 23, 2015, the Centers for Medicare and Medicaid Services released a fact sheet describing improvements to the healthcare.gov website for the 2016 open enrollment period.
To begin, the website, which reportedly will go live for shopping on October 25, will offer new shopping tools. It will add to its window shopping tool a very basic cost calculator that will allow consumers to estimate what their deductibles, copayments, and coinsurance amounts will be for particular plans depending on anticipated low, medium, or high health services utilization. The Centers for Medicare and Medicaid Services (CMS) hopes within weeks to add Doctor Lookup and Prescription Drug Lookup features that will provide consumers easily searchable information about doctors and drug coverage as they shop for coverage.
CMS has also taken a number of steps to improve the enrollment process at healthcare.gov, including the addition of:
- Directions, buttons, and page designs to better communicate information and next steps for consumers using the website.
- Tailored information to help new or returning consumers understand exactly where they are in the enrollment process and what steps remain.
- A feature that will allow reenrolling consumers to easily find out if their current plan is available for the next year and to compare it with other plans.
- Direct display on the screen for consumers determined eligible for coverage of the type of coverage they qualify for, how much financial help they can receive, and whether they need to submit more information for verification of inconsistencies. This information can also be downloadable in pdf form.
- Prompts to remind consumers to enter a Social Security number or immigration document information to avoid later verification requests.
- Easier resetting of passwords for individuals who lose access to their email accounts.
The "back-end" of healthcare.gov has also been improved to make the website perform faster with greater stability.
New Investigative Reports Released On ACA Market Marketplaces And Medicaid
Recent months have seen an outpouring of investigative reports on the functioning of the Affordable Care Act coverage expansions by a number of government agencies, including the Health and Human Services Office of Inspector General, the Treasury Inspector General for Tax Investigations, and the Government Accountability Office (GAO). On October 22 and 23, 2015, the Government Accountability Office released two reports and two transcripts of congressional testimony reporting on investigations involving the marketplaces and on the Medicaid program.
Fictitious Applications
The most sensational report involved an undercover investigation in which the GAO submitted ten fictitious applications for marketplace coverage and eight for Medicaid. The undercover investigation followed up on similar investigations in 2014. Applications were submitted in both federally facilitated (FFM) and state-based marketplace (SBM) states.
The marketplace investigation involved applicants using impossible Social Security numbers (that contained number combinations not used in Social Security numbers, such as 000), applicants who claimed employment with an employer that did not offer minimum essential coverage, and applicants already enrolled during the 2014 investigation seeking duplicate coverage in a different state. The Medicaid investigation involved applicants who did not provide a Social Security number or who submitted an impossible immigration number or an invalid Social Security identity.
The bad news is that in all but one case the fictitious applicant was able eventually to get some form of coverage. Every online application was rejected at the identity-proofing stage. But each of the ten marketplace applications was approved when the applicant subsequently contacted the call center. In each case the applicant was required to submit additional documentation to resolve inconsistencies, and in each the GAO submitted falsified documentation. But in each case the application was eventually approved and the applicant was able to enroll. In five of the eight falsified applications for Medicaid the applicant was denied Medicaid coverage but in four cases the applicant was directed to the marketplace where the applicant was able to obtain marketplace coverage.
Although these results are disappointing, they should be put in perspective. It is unlikely that falsified applications are a huge problem for the marketplace. A marketplace enrollee or Medicaid applicant receives access to insurance—not a cash benefit—and in the case of marketplace enrollment must usually pay a premium to secure the coverage. Applications must be submitted under penalty of perjury and there is a $250,000 penalty for intentionally submitting false information. Enrollees who use falsified names would have to use false identification documents each time they used a medical service. Marketplace enrollees must file taxes and reconcile the advance premium tax credits they have received at the end of the year, so a fictitious applicant would need to file a fictitious tax return.
The GAO faults CMS for not being able to detect duplicate enrollments in separate states, but how likely is it that someone would in fact enroll, and pay premiums, for coverage in separate states? Although marketplace eligibility workers review information submitted to them for obvious alterations, they do not have the capacity to submit all documents they receive to forensic examination to reveal falsification, and it is not clear that it would be cost-effective for them to do so.
Four of the applications falsely claimed that they had employer coverage not meeting minimum essential coverage requirements. As of 2016, employers will be notified whenever an employee applies claiming lack of minimum essential or minimum value coverage, which should make such false claims more difficult. Also, as of the end of 2015, the IRS will receive forms reporting employer coverage. An individual who qualified for tax credits by falsely claiming employer coverage will likely have to pay back improperly provided premium tax credits once these forms are received by the IRS.
It would seem to me that the biggest problem identified by the investigation was the inability of the marketplaces to identify obvious impossible Social Security or immigration document numbers. The most obvious candidate to file a falsified application for coverage, I would assume, would be an undocumented immigrant who would otherwise be ineligible for marketplace or Medicaid coverage. Although a Social Security number is not necessary for a marketplace application, marketplaces are supposed to verify Social Security numbers if provided, as well as immigration status. The marketplaces, and Medicaid programs, must balance program integrity concerns with their mission to expand coverage to populations that are often unfamiliar with paperwork requirements, but it would seem that eligibility workers could be expected to pay more attention to basic identity proofing requirements.
Gaps And Duplication In Coverage
A second GAO report dealt with gaps and duplications in coverage as enrollees move from marketplace to Medicaid coverage or visa versa. Because incomes often fluctuate for low-income individuals and families, movement back and forth between the programs is not uncommon. The report only identified about 73, 000 individuals who had transitioned between Medicaid and a marketplace in the three states it studied (Kentucky, New York, and Washington) in 2014, but this number may increase.
As Medicaid coverage is effective as of the date that an eligibility change is reported and can be retroactive, gaps are unlikely to occur when an individual moves from marketplace coverage to Medicaid. But marketplace coverage is usually not effective until the month following application, or even the second month following application if an individual applies after mid-month, so a gap can easily occur as an individual moves from Medicaid to exchange coverage.
Duplication of coverage is if anything more likely and can occur in several situations:
- when a person moves from marketplace coverage, which ends at the end of a month, to Medicaid, which begins immediately;
- when an individual is determined eligible for Medicaid but fails to terminate subsidized marketplace coverage; and,
- when individuals enroll in marketplace plans who are already enrolled in Medicaid.
Although Medicaid usually does not have to pay for services if an individual is also covered by a marketplace plan, duplicate coverage raises the possibility of the federal government paying twice for the same coverage if a marketplace enrollee is enrolled in a Medicaid managed care plan to which a capitation rate is paid regardless of services provided. Duplicate coverage also may result in the enrollee having to pay back any premium tax credits received at tax filing time, as individuals are not eligible for premium tax credits if they are receiving Medicaid.
The report lays out in great detail the relationship between Medicaid and marketplace coverage and recommends that CMS should improve coordination by:
- routinely monitoring timeliness of account transfers from state Medicaid programs to CMS with an eye toward real-time transfers;
- establishing a schedule for regular checks for duplicate coverage; and,
- developing a plan for routinely monitoring the effectiveness of procedures to prevent and detect duplicate coverage and take further steps as appropriate.
CMS concurred the recommendations and in fact has begun checking for duplicate coverage as of August 2015.
Another GAO report addresses needed efforts to ensure that states are correctly assigning Medicaid applicants to appropriate eligibility categories and that federal expenditures are appropriately matched to these categories, given the different levels of federal match that apply to different Medicaid categories. This report is beyond the scope of this blog.
from Health Affairs Blog http://ift.tt/1OMYkVQ
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