Last week, the House and Senate passed post-acute care legislation; the House Oversight and Government Reform Committee held a hearing on the Affordable Care Act (ACA) exchanges, enrollment and information security; the GAO released a report regarding improper coverage of abortion services by many ACA plans; and the Centers for Medicare & Medicaid Services (CMS) announced that certain individuals who failed to provide immigration documents may lose their health coverage.
ON THE HILL
The House and Senate passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 last week, which would standardize payments across four post-acute care settings if President Obama signs it. The bill would require more frequent surveys of hospice providers and facilitates medical reviews for select hospice programs for patients receiving care for more than 80 days. The bill was sponsored by House Ways and Means Chairman Dave Camp (R-Mich.)and Senate Finance Committee Chairman Ron Wyden (D-Ore.).
During a House Oversight and Government Reform hearing on September 18, CMS Administrator Marilyn Tavenner revealed an updated number for the amount of people currently enrolled in ACA exchanges. In May, CMS had reported that 8 million individuals were enrolled in ACA plans, but Tavenner reported at the hearing that the actual number is 7.3 million. Committee Chairman Darrel Issa (R-Calif.) responded to the updated figure by stating it was a “precipitous drop” from the figure reported in May. Tavenner responded by saying that enrollee numbers change due to a variety of circumstances and that the 7.3 million was still a “really strong number.”
On September 15, the GAO released a report that claims a large number of ACA insurance plans are not adhering to rules regarding payments for abortions created by provisions in the ACA. Under the law, subsidized plans offered on ACA exchanges cannot cover abortion procedures except in cases of rape, incest or where the mother’s life is at risk. If abortion services are used outside of these circumstances, customers are required to send a separate payment for those services to the insurance companies for the cost of the procedure. Using a sample of 18 insurance company plans, the GAO report found that 15 of these companies indicated that there are no restrictions on abortion coverage under their plans. An HHS official responded to the report by saying that these rules were clearly stated to insurance companies who participate on the exchanges. On September 16, HHS spokesperson Ben Wakana, said that the agency will issue additional clarifying language so that stakeholders “fully understand and comply with federal law prohibiting the use of federal funds for abortions.”
On September 16, the GAO released a report regarding the current security status of the federal ACA exchange website, Healthcare.gov. According to the report, “weaknesses” in security and privacy protections for consumers still remain, both on the main site and the systems that support it. CMS responded to the report by saying that it would work with GAO to address all of the concerns laid out in the report. The main sticking point between GAO and CMS is that GAO would prefer that the agency do one overall security assessment to identify issues. CMS, however, would prefer to review security issues individually to identify and address any concerns. GAO released the report in advance of a House Oversight and Government Reform Committee hearing that took place on September 18, during which Republican members used the GAO report, and a similar report that was produced by the Republican committee staff, to highlight problems that may negatively affect the upcoming enrollment period.
AT THE AGENCIES
CMS announced that Recovery Audit Contractors (RACs) could once again begin conducting automated and complex reviews. The Recovery Audit Contractor program identifies and recovers improper Medicare payments provider to health care providers. CMS said that current RACs could conduct the reviews until the agency awards contracts to new RACs and the program transitions to them. CMS had initially planned to award new RAC contracts by the end of 2014, but a protest by CGI Federal, Inc. is delaying the awards. In June of this year, CMS had decided to temporarily pause the program.
On September 12, CMS announced that it had awarded a total of $295 million in ACA funding to almost 1,200 health centers. The funding will allow the centers to expand the provision of primary care services, hiring new staff including primary care physicians, extending hours of operation, and expanding the type of care that is provided at the centers including oral and behavioral health care, pharmacy and vision service. CMS estimated that the grants will assist the health centers with providing care for 1.5 million new patients.
On September 15, CMS Deputy Administrator Andy Slavitt said that approximately 115,000 individuals did not respond by the September 5 deadline to CMS’ request that they provide information verifying their citizenship and immigration status. Slavitt said that if the information was not provided by September 30, the individuals would lose their coverage. However, those individuals whose coverage is terminated but are later determined to have been eligible will be able to have their coverage date retroactive to the date of termination when they provide the needed documents and pay premiums. Mr. Slavitt also said that approximately 279,000 households had not reconciled discrepancies in income between what they reported when enrolling in exchange coverage and information contained in federal tax records. CMS is giving the households until September 30 to adjust income levels they have reported. If not reconciled, the households may be required to pay higher premiums starting in November because of decreased premium subsidies or face increased tax liability in 2015 to make up for the discrepancies.
HHS’s Office of the Inspector General (OIG) released a report on certification levels for rural health clinics. According to the report, 12 percent of the facilities examined did not meet qualifications for designation as certified rural health clinics in 2013. In order to qualify as certified rural health clinics, the centers needed to be located in a rural area or in areas with shortages of health care providers. Certified rural health clinics generally receive enhanced Medicare and Medicaid reimbursement levels. However, because CMS had not issued regulations on the matter, rural health centers that no longer meet the qualification requirements also continue to receive enhanced reimbursement.
According to an analysis conducted by CMS, 64 of 243 accountable care organizations (ACOs) had savings levels sufficient to earn bonuses under the Pioneer ACO demonstration or the Medicare Shared Savings Program. The successful ACOs earned a total of $445 million in bonuses from the agency and saved the agency $372 million. The ACOs also significantly improved performance on almost all quality and patient experience measures, compared to results from last year. Despite CMS’s analysis, many believe that ACOs will not continue to succeed unless the agency makes key changes to the programs including modifying risk sharing, beneficiary attribution and benchmark calculations.
The Centers for Disease Control and Prevention (CDC) released the results of a survey on September 16 that found that the uninsured rate in the country declined after implementation of the ACA. According to the survey, 18.4 percent of adults under 65 years of age were uninsured during the first three months of 2014, compared to 20.4 percent in 2013. The CDC survey, however, did not include enrollment during late March and early April, when significant numbers of individuals also enrolled in coverage under the ACA.
CMS is projecting that enrollment in Medicare Advantage (MA) plans will reach its highest-ever levels in 2015. CMS also said that that the average MA premium submitted by health plans in 2015 will be $33.90 per month, an increase of $2.94 from last year. However, because CMS expects that more Medicare beneficiaries will choose to enroll in lower cost plans, it estimates that the average actual MA premium for 2015 will increase by only $1.30. The agency also said that quality in MA plans is improving, with 60 percent of beneficiaries enrolled in plans that earned at least four stars on CMS’s MA plan rating system.
HHS released a report on September 19 on the results of premium rate review programs. The ACA mandated state reviews of proposed premium increases of 10 percent or more. According to the report, for 2013, rate reviews decreased total premiums by approximately $290 million in the individual health insurance market, and the average requested rate increase for the individual market was reduced by 8 percent. Figures for the small group market were $703 million in premium reductions and 11 percent for the reduction in the requested rate increase. HHS said that in total, for 2013, consumers saved approximately $1 billion in premiums.
IN THE STATES
The board that manages Nevada’s state run ACA exchange website decided to discontinue its search for a new website contractor to replace Xerox. Xerox was the original contractor for the website but because of the numerous technical problems Nevada’s exchange experienced, Xerox lost its contract with the state in May. The board decided that it will continue to use the federal Healthcare.gov system for the upcoming enrollment period.
Due to technical issues with its state-run ACA exchange, Health Connector, Massachusetts extended the period for individuals to remain on temporary Medicaid plans. Close to 300,000 individuals were given temporary Medicaid coverage when Health Connector could not determine eligibility, and about 100,000 individuals remain on the state subsidized insurance plan. Originally temporary, Medicaid plans and the old state insurance plans were set to expire on December 31, 2014. That state has extended that deadline to February 15, 2015.