According to a recent study...

... the percentage of workers covered by health plans, who were enrolled in plans that were self-insured by their employers, increased from 58.2% to 60% from 2013 to 2015.

Source: "Self-Insured Health Plans: Recent Trends by Firm Size,1996‒2015, p.2," Employee Benefti Research Institute Notes, July 2016, https://www.ebri.org/pdf/notespdf/EBRI_Notes_07-no7-July16.Self-Ins.pdf

CMS examines inappropriate steering of people eligible for Medicare or Medicaid into Marketplace plans

CMS News

FOR IMMEDIATE RELEASE
August 18, 2016

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 

CMS examines inappropriate steering of people eligible for Medicare or Medicaid into Marketplace plans

Concerns raised about impact of 3rd party premium provider & affiliated organization payments

 

The Centers for Medicare & Medicaid Services (CMS) today issued a request for information seeking public comment on concerns that some health care providers and provider-affiliated organizations may be steering people eligible for, or receiving, Medicare and/or Medicaid benefits into Affordable Care Act-compliant individual market plans, including Health Insurance Marketplace plans, for the purpose of obtaining higher reimbursement rates. CMS also sent letters to all Medicare-enrolled dialysis facilities and centers informing them of this announcement.

The request for information and letters to providers focus on situations where patients may be steered away from Medicare or Medicaid benefits, which can among other concerns, result in beneficiaries experiencing a disruption in the continuity and coordination of their care as a result of changes to their network of providers. These actions reflect ongoing efforts by the CMS Center for Program Integrity to address possible issues in the Marketplace that could affect the integrity of the programs for both consumers and issuers, and the costs of the individual insurance market, while at the same time help ensure patients are enrolled in the right plan for them.

“Ensuring access to high quality patient care is a top priority for us. We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients’ needs,” said CMS Acting Administrator Andy Slavitt. “These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of Marketplace coverage for everyone.”

“It is improper to influence people away from Medicare or Medicaid coverage for the purpose of financial gain,” said Shantanu Agrawal, M.D., CMS Deputy Administrator and Director of the Center for Program Integrity. “Our goal is to protect patients from being unduly influenced in their decisions about their health insurance options, and to protect the integrity of all the programs we oversee.”

Currently, third-party payment of premiums and cost sharing of qualified health plans in the individual market by health care providers such as physicians, medical facilities or affiliated non-profit organizations are discouraged, but the ultimate decision about accepting those payments are left to health insurance companies. This guidance does not apply to certain federal, state or local government programs, Ryan White HIV/AIDS programs or Indian tribes, tribal organizations and urban Indian organizations, which are expressly permitted to pay insurance premiums for consumers under CMS regulations. Recently, concerns have been raised that certain providers or organizations affiliated with specific providers may steer consumers into individual market plans, including Marketplace health plans, because they would receive higher payment rates under a private plan than under Medicare or Medicaid. 

In addition to asking for more information on instances of problematic steering of consumers to individual market plans, CMS is also considering potential regulatory and operational options to prohibit or limit premium payments and routine waiver of cost-sharing for qualified health plans by health care providers, revisions to Medicare and Medicaid provider enrollment rules, the imposition of civil monetary penalties for individuals that fail to provide correct information about consumers enrolling in a plan, and potential changes that would allow issuers to limit their payment to health care providers to Medicare-based amounts for particular services and items of care. In particular, CMS is looking at authorities to impose civil monetary penalties on health care providers when their actions result in late enrollment penalties for Medicare eligible individuals who are steered to an individual market plan and, as a result, are delayed in enrolling in Medicare.

Like reducing inappropriate use of special enrollment periods and other efforts, today’s steps are a part of the Administration’s ongoing work to strengthen and expand the Health Insurance Marketplace. 

The request for information can be found on the Federal Register website at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-20034.pdf

The letter to all dialysis providers can be found on the CMS website at: https://www.cms.gov/about-cms/components/cpi/downloads/rfi-medicare-dialysis.pdf

Agents and brokers are still having issues with delayed access to the Marketplace Learning Management System (MLMS) ...

... when logging on to complete plan year 2017 registration and training. Make sure that you turn off your computer's pop-up blockers and review the CMS Plan Year 2017 Computer Configuration Requirements Quick Reference Guide to make any additional adjustments to your computer configuration, as needed.

 

See the quick reference guide for step-by-step instructions to address the following possible issues:

• Turn off your computer’s pop-up blockers.
• Download and use the free web browsers that work best with the MLMS: Firefox or Google Chrome.
• Download the latest version of Adobe Flash to optimize display of animations.
• Allow cookies.
• Access the training for registration on a desktop or laptop computer. (The Marketplace training cannot be accessed on a tablet or other hand-held/mobile device.)
• Check with your network provider for more assistance if you encounter bandwidth and server issues. 

Remember, you must access both the MLMS and CMS-approved vendor training via the CMS Enterprise Portal. For a better user experience, the best days and times to access registration and training are Monday through Friday, between 5:00 PM and 11:00 AM ET and on the weekends.

 

For more information on plan year 2017 registration and training, visit the Agents and Brokers Resources webpage.

"In a normal political environment ...

...  a landmark piece of legislation [like the Affordable Care Act] would be adjusted over time to improve it. ACA is far overdue for that. Republicans have not wanted to make commonsense adjustments because they have wanted the whole law to collapse. To me a major opportunity is to change the age-rating bands so that a 65-year-old can be charged 5 times what a 21-year-old is charged rather than 3 times. This will enhance the viability of the exchanges and in general make health insurance more popular among younger, healthier people."
— David Williams, co-founder of the Boston consulting firm Health Business Group, told AIS's Health Plan Week.

37 ...

... services delivered by telehealth are covered by Medicare, including emergency department or initial inpatient consultations, office or other outpatient visits, and individual psychotherapy provided in rural areas.

$241 Billion Spent on Heart Disease in 2012

Kaiser Family Foundation recently released a chart collection on heart disease spending and outcomes in the U.S. Here are some key findings from the report:

·         Heart disease mortality rate has fallen from 590 deaths per 100,000 people in 1983 to 253 in 2013.

·         U.S. disease burden for cardiovascular diseases has decreased 36% in the past 2 decades.

·         Heart disease is the leading cause of death in the U.S., accounting for 23.4% of all deaths in 2014.

·         Circulatory system diseases accounted for 8.6% of medical services spending growth from 2000-2012.

·         13% of adults earning below $35,000 experience heart disease, vs. 10% of adults earning $75,000+.

·         In 2012, spending on heart disease accounted for 13% ($241 billion) of spending on disease treatment.

Source: Peterson-Kaiser Health System Tracker, August 4, 2016

18% of Executives Use Patient-Reported Outcomes

Health Catalyst recently released results from a survey of healthcare executives' use of patient-reported outcomes (PROs). Here are some key findings from the report:

·         18% of executives always use PROs to guide clinical care.

·         Nearly 3 in 4 who said they rarely/never use PROs plan to begin using them in 1-3 years.

·         36% of respondents said "time and/or money" was the most significant barrier to using PROs.

·         1 in 4 said difficulty fitting PROs into clinicians' daily workflow is the greatest barrier.

·         Technology was listed as the most significant barrier to PRO use by 15% of respondents.

·         59% selected "chronic care tracking" when asked to list areas in which they use PROs.

Source: Health Catalyst, August 2, 2016