The Patient Protection and Affordable Care Act (ACA) brought about significant changes to the healthcare landscape in the United States, primarily through the establishment of Health Insurance Exchanges. These exchanges are designed to provide individuals and small businesses with access to affordable health insurance plans. However, the success and sustainability of the ACA rely heavily on program integrity – the measures and processes put in place to prevent fraud, waste, and abuse, ensuring that the program operates as intended and taxpayer dollars are used appropriately.
This article, drawing from official regulatory documents, delves into the key aspects of Affordable Care Act Program Integrity, focusing on how regulations are being strengthened to enhance oversight, verification, and accountability within the healthcare exchanges. Understanding these measures is crucial for stakeholders, including enrollees, issuers, and state and federal agencies, to appreciate the ongoing efforts to maintain the integrity of this vital healthcare program.
I. Strengthening Exchange Oversight for Program Integrity
One of the fundamental pillars of Affordable Care Act program integrity is robust oversight of the Exchanges themselves. The Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services (HHS), plays a critical role in overseeing state-established Exchanges and ensuring they adhere to federal standards.
A. Clarifying Exchange Oversight Functions
Regulations have been revised to explicitly state that Exchanges must perform broad oversight functions, cooperating fully with oversight activities as mandated by Section 1313 of the PPACA and 45 CFR Part 155. This clarification reinforces that Exchanges are not just marketplaces for insurance, but also entities responsible for program integrity.
This includes:
- General Oversight: Exchanges are expected to oversee all aspects of their operations to prevent fraud, waste, and abuse. This is not limited to activities explicitly listed in Section 1313 of the PPACA, but encompasses a wider range of program integrity functions.
- Cooperation with Oversight Entities: Exchanges are required to cooperate with government oversight entities, such as state departments of insurance, in investigations related to fraudulent behavior, particularly involving agents and brokers. This cooperation may involve the disclosure of Personally Identifiable Information (PII) when necessary for program integrity efforts.
- Oversight of Programs and Entities: The oversight responsibility extends to Exchange programs, Navigators, agents, brokers, and other non-Exchange entities that interact with the Exchange system and applicant information. This ensures a comprehensive approach to program integrity, covering all touchpoints within the Exchange ecosystem.
This clarification aims to remove any ambiguity about the scope of Exchange oversight and empower them to effectively combat potentially fraudulent activities, contributing directly to affordable care act program integrity.
II. Enhancing Data Matching for Eligibility Verification: A Key Program Integrity Measure
Maintaining program integrity within the Affordable Care Act also relies heavily on accurate eligibility determinations for financial assistance programs like Advance Premium Tax Credits (APTC) and Cost-Sharing Reductions (CSRs). To ensure that subsidies are correctly allocated and prevent improper payments, regulations emphasize periodic data matching (PDM) with other federal and state programs.
A. Periodic Data Matching (PDM) Frequency Increased
Regulations have been updated to mandate that Exchanges must conduct periodic data matching (PDM) at least twice each calendar year, starting in 2021. This increased frequency applies to data matching with:
- Medicare: To identify enrollees who may also be eligible for or enrolled in Medicare, which could affect their eligibility for APTC and CSRs.
- Medicaid and CHIP: To verify enrollment in Medicaid and the Children’s Health Insurance Program (CHIP), ensuring individuals are not inappropriately receiving subsidies through the Exchange while also enrolled in these programs.
- Basic Health Program (BHP): In states with a BHP, PDM is also required to prevent dual enrollment and improper subsidy allocation.
This move to a minimum twice-yearly PDM frequency strengthens affordable care act program integrity by:
- Reducing Improper Payments: Identifying and correcting dual enrollment issues more frequently minimizes the risk of incorrect subsidy payments and potential taxpayer liability.
- Improving Risk Pool Integrity: Individuals eligible for Medicare or Medicaid/CHIP often have different risk profiles than the general Exchange population. Regular PDM helps maintain a balanced risk pool within the Exchanges.
- Ensuring Accurate Subsidy Allocation: Periodic checks ensure that APTC and CSRs are provided only to those who are truly eligible, safeguarding the financial integrity of the program.
B. Streamlined Eligibility Systems for Medicaid/CHIP PDM
Recognizing that many State Exchanges already have integrated eligibility systems with their Medicaid agencies, regulations acknowledge these existing systems for meeting Medicaid/CHIP PDM requirements.
- Integrated Eligibility Systems: State Exchanges with “fully integrated eligibility systems” – meaning they share a single eligibility rules engine with their Medicaid program for MAGI-based eligibility determinations – are deemed to be in compliance with Medicaid/CHIP and BHP PDM requirements.
- Reduced Burden: This recognition reduces the burden on these states, as they do not need to implement additional PDM processes beyond their existing integrated systems.
- Focus on Medicare PDM: All Exchanges, including those with integrated systems, are required to conduct Medicare PDM at least twice a year, ensuring comprehensive data matching across key programs.
These provisions aim to streamline PDM processes while ensuring robust verification, further enhancing affordable care act program integrity.
III. Enhancing Financial Accountability through Program Audits
Financial accountability and transparency are crucial for maintaining public trust and ensuring the long-term viability of the Affordable Care Act. Regulations mandate annual program audits for State Exchanges to assess their compliance and financial integrity.
A. Strengthening Annual Program Audit Requirements
Regulations have been refined to strengthen the annual program audit requirements for State Exchanges, focusing on key areas relevant to affordable care act program integrity.
- Annual Compliance Reports: State Exchanges are required to submit annual compliance reports, such as the State-based Marketplace Annual Reporting Tool (SMART), encompassing eligibility and enrollment reporting, along with compliance across other Exchange program requirements.
- Targeted Programmatic Audits: HHS has clarified its authority to specify or target the scope of programmatic audits. This allows for focusing audits on particular Exchange program areas or requirements that are most critical for program integrity or relevant to a specific State Exchange model (e.g., State-Based Exchange on the Federal Platform – SBE-FP).
- Eligibility and Enrollment Accuracy Audits: Audits must include procedures to assess whether State Exchanges are conducting accurate eligibility determinations and enrollment transactions. This can include using statistically valid sampling methods to ensure the reliability of audit findings.
These strengthened audit requirements are designed to:
- Improve Oversight Precision: Targeted audits allow HHS to focus oversight resources on areas with the highest risk of program integrity issues, leading to more effective and efficient oversight.
- Enhance Financial Accountability: Annual audits ensure that State Exchanges are operating with financial integrity and in compliance with federal regulations.
- Promote Corrective Actions: Audit findings help identify areas for improvement and prompt State Exchanges to develop and implement corrective action plans to address any identified weaknesses.
By strengthening program audit requirements, regulations contribute to greater financial accountability and overall affordable care act program integrity.
IV. Addressing Separate Billing for Abortion Services: Ensuring Proper Fund Segregation
A specific area of focus for program integrity within the Affordable Care Act relates to the coverage of abortion services and the use of federal funds. Section 1303 of the ACA sets forth requirements to ensure that no premium tax credits or cost-sharing reduction funds are used to pay for abortion services for which public funding is prohibited (non-Hyde abortion services).
A. Refining Separate Billing Requirements for Non-Hyde Abortion Services
Regulations have been updated to refine the billing and payment processes for the portion of a health plan premium attributable to coverage for non-Hyde abortion services. These changes aim to enhance compliance with Section 1303 and ensure proper segregation of funds.
- Separate Monthly Bill: Issuers of Qualified Health Plans (QHPs) that cover non-Hyde abortion services are now required to send an entirely separate monthly bill to policyholders specifically for the portion of the premium related to this coverage. This bill must be distinct from the bill for all other services.
- Separate Payment Transaction: Policyholders are instructed to make a separate payment for this abortion services portion of the premium, distinct from their payment for the rest of their health plan premium.
- Fund Segregation: Issuers must continue to segregate funds collected for non-Hyde abortion services into a separate allocation account, ensuring these funds are used solely for these specific services.
These refined billing requirements are intended to:
- Enhance Transparency: The separate bill aims to provide greater transparency to policyholders regarding the portion of their premium dedicated to non-Hyde abortion services.
- Strengthen Fund Segregation: The requirement for separate billing and payment is intended to reinforce the segregation of funds, ensuring compliance with Section 1303 of the ACA.
- Address Congressional Intent: HHS believes these changes better reflect Congressional intent regarding the separate payment requirement for abortion services coverage.
While these changes have generated debate and concerns regarding potential enrollee confusion and administrative burden, they are presented as necessary to strengthen affordable care act program integrity in a specific and sensitive area of healthcare coverage.
Conclusion: A Continuous Commitment to Affordable Care Act Program Integrity
The Affordable Care Act represents a significant investment in the nation’s healthcare system. Maintaining affordable care act program integrity is paramount to ensuring its continued success, public trust, and responsible use of taxpayer resources. The regulatory updates discussed in this article demonstrate an ongoing commitment to strengthening oversight, enhancing verification processes, and ensuring financial accountability within the healthcare exchanges. These measures, while sometimes complex and debated, are essential for safeguarding the program against fraud, waste, and abuse, and for ensuring that the ACA effectively serves its intended purpose of expanding access to affordable healthcare coverage for millions of Americans.
