On November 2, the Centers for Disease Control and Prevention’s National Center for Health Statistics released its quarterly report on health insurance coverage, for January to June 2016. The dramatic reductions in the number of the uninsured that have occurred over the past three years as the Affordable Care Act has been implemented have leveled off for 2016. During the first six months of 2016, 28.4 million people (8.9 percent of the population) were uninsured, 20.2 million fewer than in 2010 but only 0.2 million fewer than in 2015. Of adults between the ages of 18 and 64, 12.4 percent remain uninsured, as do 5 percent of children. The uninsured percentage of the population has fallen for all age, income, and ethnic groups since 2010.
The report shows few significant changes between 2015 and the first six months of 2016. It does show an uptick between 2015 and the first half of 2016 in the percentage of poor children who are uninsured, from 4.4 to 6.6 percent. There was also a significant decrease between 2015 and the first half of 2016 in the percentage of adults uninsured for more than a year, from 9.1 percent to 7.6 percent. Finally, the percentage of privately insured persons with a high-deductible health plan continues to grow year over year, from 36.7 percent in 2015 to 38.8 percent in the first half of 2016, up from 25.3 percent in 2010. Of the 38.8 percent with high-deductible health plans, fewer than two in five (15.3 percent of all privately insured individuals) have a health savings account.
Hospitals And Patient Safety
One of the less well-known provisions of the Affordable Care Act and implementing regulations requires qualified health plan insurers that contract with hospitals with more than 50 beds to verify that, as of January 1, 2017, those hospitals either 1) have in place a patient safety evaluation system and implement a mechanism for comprehensive person-centered hospital discharge to improve care coordination and health care quality for patients, or 2) otherwise implement an evidence-based initiative to improve health care quality through the collection, management, and analysis of patient safety events that reduces preventable harm, prevents hospital readmission, or improves care coordination. On November 3, 2016, CMS released at its REGTAP.info website a series of frequently asked questions relating to this requirement.
These clarify that the requirement does not apply to hospitals with fewer than 50 beds or to psychiatric hospitals, but it does apply to hospital entities (including long-term acute care or rehabilitation hospitals) that include in aggregate more than 50 beds located in different locations. Qualified Health Plan insurers in federally facilitated marketplaces are expected to collect documentation demonstrating compliance by January 1, 2017. This documentation could include current agreements from hospitals to partner with Patient Safety Organizations, Hospital Engagement Networks, or Quality Improvement Organizations or documentation of an evidence-based initiative as described in the regulations.
Insurer Cost-Sharing Reduction Payment Reconciliation
On November 2, 2016, CMS released at its REGTAP.info website a Draft Manual for Reconciliation of the Cost-Sharing Reduction (CSR) Component of Advance Payments for Benefit Year 2016. Each month qualified health plan (QHP) insurers receive advance payments for the CSRs—reductions in deductibles, coinsurance, copayments, and out-of-pocket limits—that they are required to offer their low-income and Native American enrollees for essential health benefits (EHBs). Each year, these advance payments must be reconciled with the payments the insurers were actually due. The draft manual proposes how this reconciliation process should take place for 2016 and how corrections should be made for 2014 and 2015 cost sharing reduction (CSR) reconciliations.
Data submission for the reconciliation process for 2016 will begin on April 3, 2017; it must be completed by June 2, 2017. Claims settled after that point can be submitted in 2018 in restatements of 2016 filings. Claims for 2015 not included in 2015 reconciliation filings may be submitted in restatements of the 2015 CSR reconciliation data, but 2014 is closed at this point and 2014 data can be restated only for claims that were subject to appeal or presented other unusual circumstances.
After 2016, all insurers will have to use the “standard methodology” for CSR reconciliation. Under the standard methodology, all claims for EHB for each policy for which CSRs are due must be re-adjudicated as though all EHB claims had been submitted under the insurer’s standard silver plan that is associated with the CSR plan. The difference between the amount of cost-sharing under the CSR variation and the standard plan must be reconciled with advance CSR payments actually received.
Recognizing that some insurers may not have the technical capacity to re-adjudicate claims, CMS allowed insurers to use simplified methodologies for 2014, 2015, and 2016. These “simplified” methodologies are in fact very complex and the methodology that must be applied varies depending on the number of claims an insurer has in various categories and whether the insurer pays on a fee-for-service or capitated basis. The simplified methodologies were described in my Health Affairs Blog post on last year’s draft manual.
The 2016 draft manual is very similar to the 2015 manual, but incorporates guidance that CMS has provided over the first two years of CSR reconciliation and includes updated attestations and additional information on how CMS will handle reporting outliers, how insurers should address discrepancies related to data reporting errors, and how restatements for earlier years should be handled. Comments on the draft manual are due by December 2, 2016.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2f9Jom5
No comments:
Post a Comment