Kathleen Sebelius

Nearly 2.2 million Americans selected plans in the Health Insurance Marketplace from October through December

Thirty percent of those who selected plans were under age 35

Nearly 2.2 million people have selected plans from the state and federal marketplaces by Dec. 28, 2013 (the end of third reporting period for open enrollment), Health and Human Services Secretary Kathleen Sebelius announced today.

A new HHS report provides the first demographic information about enrollees. December alone accounted for nearly 1.8 million enrollees in state and federal marketplaces. Enrollment in the federal Marketplace in December was seven-fold greater than the combined total for October and November – and eight-fold greater for young adults ages 18 to 34.

“Americans are finding quality affordable coverage in the Marketplace, and best of all, because coverage began on New Year’s Day, the promise and hope of the Affordable Care Act is now a reality,” Secretary Sebelius said. “Our outreach efforts have ramped up, so whether it’s through public service announcements, events, our champions or other means, we are doing all we can to find, inform and enroll those who can benefit from the Marketplace.  There is still plenty of time for you and your family to sign up in a private plan of your choice, so visit HealthCare.gov to learn more and sign up now.”

Key findings from today’s report include:

  • Nearly 2.2 million (2,153,421) people selected Marketplace plans from Oct. 1 through Dec. 28, 2013
  • These signups in the state and federal marketplaces represent a nearly five-fold increase from October-November, including nearly 1.8 million (1,788,739) people who selected a plan in December (compared with the previous two-month cumulative total of 364,682 through Nov. 30, 2013).
  • Of the almost 2.2. million:
    • 54 percent are female and 46 percent are male;
    • 30 percent are age 34 and under;
    • 24 percent are between the ages of 18 and 34, and;
    • 60 percent selected a Silver plan, while 20 percent selected a Bronze plan; and
    • 79 percent selected a plan with Financial Assistance.

Today’s report also details state-by-state information where available.  In some cases, only partial datasets were available for state marketplaces.

The report features cumulative data for the three-month period because some people apply, shop, and select a plan across monthly reporting periods.  Enrollment is measured as those who selected a plan.

To read the report visit:  http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Jan2014/ib_2014jan_enrollment.pdf

To hear stories of Americans enrolling in the Marketplace visit:  http://www.hhs.gov/healthcare/facts/mystory/index.html

HHS strengthens community living options for older Americans and people with disabilities

 

imagesThe Centers for Medicare & Medicaid Services (CMS) issued a final rule today to ensure that Medicaid’s home and community-based services programs provide full access to the benefits of community living and offer services in the most integrated settings. The rule, as part of the Affordable Care Act, supports the Department of Health and Human Services’ Community Living Initiative. The initiative was launched in 2009 to develop and implement innovative strategies to increase opportunities for Americans with disabilities and older adults to enjoy meaningful community living.

Under the final rule, Medicaid programs will support home and community-based settings that serve as an alternative to institutional care and that take into account the quality of individuals’ experiences.  The final rule includes a transitional period for states to ensure that their programs meet the home and community-based services settings requirements.  Technical assistance will also be available for states.

“People with disabilities and older adults have a right to live, work, and participate in the greater community.  HHS, through its Community Living Initiative, has been expanding and improving the community services necessary to make this a reality,” said HHS Secretary Kathleen Sebelius. “Today’s announcement will help ensure that all people participating in Medicaid home and community-based services programs have full access to the benefits of community living.”

In addition to defining home and community-based settings, the final rule implements the Section 1915(i) home and community-based services State Plan option. This includes new flexibility provided by the Affordable Care Act that gives states additional options for expanding home and community-based services and to target services to specific populations.  It also amends the 1915(c) home and community-based services waiver program to add new person-centered planning requirements, allow states to combine multiple target populations in one waiver, and streamlines waiver administration.

For more information about the final rule, please visit:  http://cms.gov/Newsroom/Search-Results/index.html?q=&filter=Press%20Releases+Fact%20Sheets&date-from=&date-to=

For more information regarding the Home and Community-Based Services available under Medicaid, please visit:http://www.medicaid.gov/HCBS

For more information regarding the Community Living Initiative, please visit:http://www.hhs.gov/od/community/index.html

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By The Numbers: the First Reporting Period of Open Enrollment

By Kathleen Sebelius, Secretary of Health and Human Services

Today we released our most detailed report to date about the results of the first reporting period of open enrollment in the Health Insurance Marketplace. The numbers show that interest in the Health Insurance Marketplace remains strong and the promise of quality, affordable coverage is becoming a reality for hundreds of thousands of Americans.

Marketplace Open Enrollment: 1st Reporting Period: October 1st Through November 2nd 106,185 Americans have enrolled in a plan through the Marketplace. 975,407 Americans have made it through the process and have not yet selected a plan. 502,466 Americans are positioned to have health coverage starting in 2014 through Medicaid/CHIP. 26,876,527 unique visitors to Marketplace websites. 3,158,436 calls to the federal & state call centers. “The promise of quality affordable coverage is increasingly becoming reality for this first wave of applicants to the Health Insurance Marketplaces. There is no doubt the level of interest is strong. We expect enrollment will grow substantially throughout the next five months, mirroring the pattern that Massachusetts experienced. We also expect that the numbers will grow as the website, HealthCare.gov, continues to make steady improvements.” – Secretary Kathleen Sebelius HealthCare.gov.

Between October 1 and November 2, 2013, 106,185 individuals selected plans from the Marketplace and another 975,407 applied and received an eligibility determination, but have not yet selected a plan. An additional 396,261 were determined eligible for Medicaid or the Children’s Health Insurance Program (CHIP).  In total, 502,446 Americans will be positioned to have health coverage starting in 2014.

As we’ve seen in Massachusetts’s efforts to expand coverage, I expect the number of newly insured to grow substantially throughout the open enrollment period. Our efforts to improve HealthCare.gov will be critical to driving new enrollments and meeting consumer demand.

As a further indication of high consumer interest, web traffic and call center volume also continues to be very heavy. During the first reporting period, there have been over 26 million unique visitors to Marketplace websites and over 3.1 million calls to the call centers.

While we know there is still a lot of work to do to make sure every American that wants access to affordable coverage can have it, there are many encouraging takeaways from today’s report.

For the full text of the report, “Health Insurance Marketplace: November Enrollment Report,” please visit:  http://aspe.hhs.gov/health/reports/2013/MarketPlaceEnrollment/rpt_enrollment.pdf

Nevada has a state supported exchange, meaning we don’t need to use the national website.  We can go to our own exchange website.  If you don’t have employer provided insurance and will need to enroll for insurance, VISIT THE NEVADA HEALTH LINK NOW TO APPLY today.

HHS announces first guidance implementing Supreme Court’s decision on the Defense of Marriage Act

Today, the Department of Health and Human Services (HHS) issued a memo clarifying that all beneficiaries in private Medicare plans have access to equal coverage when it comes to care in a nursing home where their spouse lives.  This is the first guidance issued by HHS in response to the recent Supreme Court ruling, which held section 3 of the Defense of Marriage Act unconstitutional.

“HHS is working swiftly to implement the Supreme Court’s decision and maximize federal recognition of same-sex spouses in HHS programs,” said HHS Secretary Kathleen Sebelius.  “Today’s announcement is the first of many steps that we will be taking over the coming months to clarify the effects of the Supreme Court’s decision and to ensure that gay and lesbian married couples are treated equally under the law.”

“Today, Medicare is ensuring that all beneficiaries will have equal access to coverage in a nursing home where their spouse lives, regardless of their sexual orientation,” said Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner.  “Prior to this, a beneficiary in a same-sex marriage enrolled in a Medicare Advantage plan did not have equal access to such coverage and, as a result, could have faced time away from his or her spouse or higher costs because of the way that marriage was defined for this purpose.”

Under current law, Medicare beneficiaries enrolled in a Medicare Advantage plan are entitled to care in, among certain other skilled nursing facilities (SNFs), the SNF where their spouse resides (assuming that they have met the conditions for SNF coverage in the first place, and the SNF has agreed to the payment amounts and other terms that apply to a plan network SNF).  Seniors with Medicare Advantage previously may have faced the choice of receiving coverage in a nursing home away from their same-sex spouse, or dis-enrolling from the Medicare Advantage plan which would have meant paying more out-of-pocket for care in the same nursing home as their same-sex spouse.

Today’s guidance clarifies that this guarantee of coverage applies equally to all married couples.  The guidance specifically clarifies that this guarantee of coverage applies equally to couples who are in a legally recognized same-sex marriage, regardless of where they live.
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Holding Insurance Companies Accountable for High Premium Increases

— by Kathleen Sebelius, Secretary of Health and Human Services

The Affordable Care Act (ACA) prohibits some of the worst insurance industry practices that have kept affordable health coverage out of reach for millions of Americans.  It provides families and individuals with new protections against discriminatory rates due to pre-existing conditions, holds insurance companies accountable for how they spend your premium dollars, and prevents insurance companies from raising your insurance premium rates without accountability or transparency.

For more than a decade before the ACA health insurance premiums had risen rapidly, straining the pocketbooks of American families and businesses.  Oftentimes, insurance companies were able to raise rates without explanation to consumers or public justification of their actions.

One of the provisions of the ACA is that insurance companies must now reveal the percentage of premium dollars they actually spend on health care and how much they spend on administration (e.g., salaries and marketing. Prior to ACA, this type of information was a closely held secret and insurance companies pocketed a good percentage of your premium dollars. With ACA in place, that’s no longer the case. If an insurance company spends less than 80% of premiums on medical care and quality (or less than 85% in the large employer, large group market), it must rebate the portion of premium dollars that exceeded this limit. This 80/20 rule is commonly known as the Medical Loss Ratio (MLR) rule

Chart showing the percent of rate filings that requested increases of 10 percent or more. 2009: 72%, 2010: 75%, 2011: 51%, 2012: 34%, 2013: 14% Rate Review in Action
The ACA brought an unprecedented level of scrutiny and transparency to health insurance rate increases by requiring insurance companies in every state to publicly justify their actions if they want to raise rates by 10% or more.  Insurance companies are required to provide easy to understand information to their customers about their reasons for significant rate increases, and any unreasonable rate increases are posted online.

And it’s working.  A new report released today shows that the health care law is helping to moderate premium hikes.  Since this rule was implemented, the number of requests for insurance premium increases of 10% or more has dropped dramatically, from 75% to 14%.  The average premium increase for all rates in 2012 was 30% below what it was in 2010. And available data suggest that this slowdown in rate increases has continued into 2013.

Moreover, when an insurer does decide to increase rates, consumers are seeing lower rate increases than what the insurers initially requested.  In the review of rate requests for 10% or more, over 50% resulted in customers receiving either a lower rate increase than requested or no increase at all.

States have received $250 million in Health Insurance Rate Review Grants to help strengthen and improve their rate review processes thanks to the Affordable Care Act.  Of the 44 states that received rate review grants, 40 have reported enhancements to their rate review websites.  These website enhancements include searchable rate filings, new public comment options, live streaming of rate hearings, and plain language explanations of rate review and rate filings.

The Effective Rate Review program is one of many in the health care law aimed at protecting consumers.  The rate review program works in conjunction with the 80/20 rule, which requires insurance companies to generally spend 80% of premiums on health care or provide rebates to their customers. Insurance companies that did not meet the 80/20 rule have provided nearly 13 million Americans with more than $1.1 billion in rebates. Americans receiving the rebate will benefit from an average rebate of $151 per household.

Additionally, today we issued a final rule that implements five key consumer protections from the Affordable Care Act, including protection against denial of health coverage because of a pre-existing condition.  This rule makes the health insurance market work better for individuals, families and small businesses, and it also increases the transparency brought to rate increases by directing insurance companies in every state to file all of their rate increase requests.

For more information about the Affordable Care Act, visit http://www.healthcare.gov/index.html.

Related Posts

Obamacare Moves Forward to Implement Pre-Existing Condition Discrimination Ban

The Obama administration moved forward today to implement provisions in the health care law that would make it illegal for insurance companies to discriminate against people with pre-existing conditions. The provisions of the Affordable Care Act also would make it easier for consumers to compare health plans and employers to promote and encourage employee wellness.

“The Affordable Care Act is building a health insurance market that works for consumers,” said Health and Human Services Secretary Kathleen Sebelius. “Thanks to the health care law, no one will be discriminated against because of a pre-existing condition.”

“The Affordable Care Act recognizes that well-run, equitable workplace wellness programs allow workers to access services that can help them and their families lead healthier lives,” said Secretary of Labor Hilda L. Solis.  “Employers, too, can benefit from reduced costs associated with a healthier workforce.”

The Obama administration issued:

  • A proposed rule that, beginning in 2014, prohibits health insurance companies from discriminating against individuals because of a pre-existing or chronic condition.  Under the rule, insurance companies would be allowed to vary premiums within limits, only based on age, tobacco use, family size, and geography.  Health insurance companies would be prohibited from denying coverage to any American because of a pre-existing condition or from charging higher premiums to certain enrollees because of their current or past health problems, gender, occupation, and small employer size or industry. The rule would ensure that people for whom coverage would otherwise be unaffordable, and young adults, have access to a catastrophic coverage plan in the individual market.  For more information regarding this rule, visit: http://www.healthcare.gov/news/factsheets/2012/11/market-reforms11202012a.html.
  • A proposed rule outlining policies and standards for coverage of essential health benefits, while giving states more flexibility to implement the Affordable Care Act. Essential health benefits are a core set of benefits that would give consumers a consistent way to compare health plans in the individual and small group markets. A companion letter on the flexibility in implementing the essential health benefits in Medicaid was also sent to states.  For more information regarding this rule, visit http://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html.
  • A proposed rule implementing and expanding employment-based wellness programs to promote health and help control health care spending, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status.  For more information regarding this rule, visit:http://www.healthcare.gov/news/factsheets/2012/11/wellness11202012a.html

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Health Care Law Saved an Estimated $2.1B for Consumers

FOR IMMEDIATE RELEASE
September 11, 2012
Contact: U.S. Dept of HHS
202-690-6343

The health care law – the Affordable Care Act – has saved consumers an estimated $2.1 billion on health insurance premiums according to a new report released today by the Department of Health and Human Services.  For the first time ever, new rate review rules in the health care law prevent insurance companies in all states from raising rates with no accountability or transparency.  To date, rate review has helped save an estimated $1 billion for Americans.  Additionally, the law’s Medical Loss Ratio (or 80/20) rule is helping deliver rebates worth $1.1 billion to nearly 13 million consumers.

“The health care law is holding insurance companies accountable and saving billions of dollars for families across the country,” Secretary Kathleen Sebelius said. “Thanks to the law, our health care system is more transparent and more competitive, and that’s saving Americans real money.”

Beginning Sept. 1, 2011, the health care law implemented federal rate review standards. These rules ensure that, in every state, insurance companies are required to publicly submit for review and justify their actions if they want to raise rates by 10 percent or more.

To assist states in this effort, the Affordable Care Act provides states with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process. 42 states have used their rate review grant funds to make the rate review process stronger and more transparent.

These rules have brought more transparency and accountability to our health insurance marketplace and saved money for consumers. The report released today shows that because of rate review, consumers saved approximately $1 billion in premiums in the individual and small group markets.

This initiative is one of many in the health care law aimed at saving money for consumers and specifically works in conjunction with the 80/20 rule, which requires insurance companies to generally spend 80 percent of premiums on health care or provide rebates to their customers. Insurance companies that did not meet the 80/20 rule will provide nearly 13 million Americans with more than $1.1 billion in rebates this year. Americans receiving the rebate will benefit from an average rebate of $151 per household. The rate review report released today is available at:  http://www.healthcare.gov/law/resources/reports/rate-review09112012a.html.

Information on how states are using their rate review grant funds is available at:http://www.healthcare.gov/law/resources/reports/rate-review09202011a.pdf (PDF – 268 KB)

General information about rate review is available at: http://www.healthcare.gov/law/features/costs/rate-review/

HHS announces 89 new Accountable Care Organizations

FOR IMMEDIATE RELEASE
July 9, 2012
Contact: HHS Press Office
(202) 690-6343

2.4 million people with Medicare to receive better, more coordinated care

Health and Human Services (HHS) Secretary Kathleen Sebelius announced today, that as of July 1, 89 new Accountable Care Organizations (ACOs) began serving 1.2 million people with Medicare in 40 states and Washington, D.C.  ACOs are organizations formed by groups of doctors and other health care providers that have agreed to work together to coordinate care for people with Medicare.

These 89 new ACOs have entered into agreements with CMS, taking responsibility for the quality of care they provide to people with Medicare in return for the opportunity to share in savings realized through high-quality, well-coordinated care.

“Better coordinated care is good for patients and it saves money,” said Secretary Sebelius. “We applaud every one of these doctors, hospitals, health centers and others for working together to ensure millions of people with Medicare get better, more patient-centered, coordinated care.”

Participation in an ACO is purely voluntary for providers.  The Medicare Shared Savings Program (MSSP), and other initiatives related to ACOs, is made possible by the 2010 Affordable Care Act.  Federal savings from this initiative could be up to $940 million over four years.

“This new group of ACOs adds to a solid foundation,” said Centers for Medicare & Medicaid (CMS) Acting Administrator Marilyn Tavenner. “The Medicare ACO program opened for business in January and, already, more than 2.4 million beneficiaries are receiving care from providers participating in these important initiatives.”

The 89 ACOs announced today bring the total number of organizations participating in Medicare shared savings initiatives to 154, including the 32 ACOs participating in the testing of the Pioneer ACO Model by CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced last December, and six Physician Group Practice Transition Demonstration organizations that started in January 2011.  In all, as of July 1, more than 2.4 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.

The selected ACOs operate in a wide range of areas of the country and almost half are physician-driven organizations serving fewer than 10,000 beneficiaries, demonstrating that smaller organizations are interested in operating as ACOs.   Their models for coordinating care and improving quality vary in response to the needs of the beneficiaries in the areas they are serving.

To ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely, an ACO must meet quality standards.  For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.

Beginning this year, new ACO applications will be accepted annually.  The application period for organizations that wish to participate in the MSSP beginning in January 2013 is from Aug. 1 through Sept. 6, 2012.  More information, including application requirements, is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Application.html

To learn more about the ACOs announced today, visit: http://www.cms.gov/apps/media/fact_sheets.asp

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Health Coverage Options for Graduating Students

FOR IMMEDIATE RELEASE
May 21, 2012
Contact: HHS Press Office
(202) 690-6343

Secretaries Duncan and Sebelius remind graduating students
of new health coverage options under health care law

Secretaries reach out to college presidents, student associations;
outreach tools available at www.HealthCare.gov

Education Secretary Arne Duncan and Health and Human Services Secretary Kathleen Sebelius are reaching out to campus leaders to remind graduating high school, college and university seniors about their new health insurance options under the Affordable Care Act – the health care law.

Because of the new law, many young adults will be eligible to remain on their parent’s health plan until their 26th birthday. The Secretaries sent letters to college and university presidents as well as student associations encouraging them to spread that information to college students.

“The Affordable Care Act now gives students and their families peace of mind about their health insurance,” said Secretary Sebelius. “The President’s health law gives hard-working, middle-class families the security they deserve.”

In the past, many young adults were removed from their parent’s health plan when they graduated from college or high school. Previously, young adults were about twice as likely as older adults to lose private health coverage due to aging out of coverage. However, because of the health care law, 2.5 million more young adults have gained health coverage since September 2010.

“By partnering with school leaders, we hope more young Americans are aware of their options so they can access the care they need to stay healthy,” said Secretary Duncan. “Many graduates are focusing on paying back student loans in a tough economy – they don’t need to take on the cost of high medical bills, too.”

The letter outlined ways university officials and student leaders can reach out to graduating students including:

  • Universities or student groups can post a new “badge” on their websites that automatically links to information on how students can remain on a parents’ health insurance plan. Download the badge.
  • Brochures outlining the new benefits can be distributed to students and are available for download here.
  • Staff can talk to students about other insurance options— including improvements to student health plans starting this summer thanks to the health care law.
  • Information for young adults and parents about coverage for individuals under age 26 is available on a Facebook page. Exit disclaimer icon.

The letter can be found at
http://www.healthcare.gov/law/resources/letters/young-adults05212012a.html and http://www.healthcare.gov/law/resources/letters/young-adults05212012a.pdf

Medicare Fraud Task Force Nets $452M

OR IMMEDIATE RELEASE
May 2, 2012
Contact: HHS Press Office
(202) 690-6343

Medicare Fraud Strike Force charges 107 individuals for approximately $452 million in false billing

Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder announced today that a nationwide takedown by Medicare Fraud Strike Force operations in seven cities has resulted in charges against 107 individuals, including doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $452 million in false billing.

Attorney General Holder and Secretary Sebelius were joined in the announcement by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division, Federal Bureau of Investigations (FBI) Deputy Director Sean Joyce, Deputy Inspector General for Investigations Gary Cantrell of the HHS Office of Inspector General (HHS-OIG) and Dr. Peter Budetti, Deputy Administrator for Program Integrity of the Centers for Medicare & Medicaid Services (CMS).

This coordinated takedown involved the highest amount of false Medicare billings in a single takedown in Strike Force history.

HHS also suspended or took other administrative action against 52 providers following a data-driven analysis and credible allegations of fraud.  The new health care law, the Affordable Care Act, significantly increased HHS’ ability to suspend payments until an investigation is complete.

The joint Department of Justice and HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques.  More than 500 law enforcement agents from the FBI, HHS-OIG, multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the takedown.  In addition to making arrests, agents also executed 20 search warrants in connection with ongoing Strike Force investigations.

“The results we are announcing today are at the heart of an administration-wide commitment to protect American taxpayers from health care fraud, which can drive up costs and threaten the strength and integrity of our health care system,” said Attorney General Holder.  “We are determined to bring to justice those who violate our laws and defraud the Medicare program for personal gain.  As today’s takedown reflects, our ongoing fight against health care fraud has never been more coordinated and effective.”

“Today’s arrests send a strong message to criminals that the consequences of committing Medicare fraud are serious,” said HHS Secretary Sebelius.  “In addition to these arrests, we used new authority from the health care law to stop all future payments to 52 health care providers suspected of fraud before they are ever made.  Today’s actions are another example of how the Affordable Care Act is helping the Obama administration fight fraud and strengthen Medicare.”

The defendants charged are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering.  The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services.

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes never provided.  In many cases, court documents allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $452 million in fraudulent billing.

“As charged in the indictments, these fraud schemes were committed by people up and down the chain of health care providers,” said Assistant Attorney General Breuer.  “Today’s operations mark the fourth in a series of historic Medicare fraud takedowns over the past two years.  These indictments remind us that Medicare is an attractive target for criminals.  But it should also remind those criminals that they risk prosecution and prison time every time they submit a false claim.”

“Health care fraud is not a victimless crime,” said FBI Deputy Director Joyce.  “Every person who pays for health care benefits, every business that pays higher insurance costs to cover their employees, every taxpayer who funds Medicare—all are victims.  The FBI will continue to work closely with our federal, state and local law enforcement partners to address health care vulnerabilities, fraud and abuse.  We will use every tool we have to ensure our health care dollars are used to care for the sick—not to line the pockets of criminals.”

“Today more than 200 OIG Special Agents, Forensic Examiners and Analysts have deployed throughout the country to ensure that those responsible for committing Medicare fraud are held accountable,” said HHS-OIG Deputy Inspector General Cantrell.  “OIG is committed to the strike force model and will continue to use advanced data analytics along with traditional investigative methods to root out those who steal from our Medicare program.”

In Miami, a total of 59 defendants, including three nurses and two therapists, were charged today and yesterday for their participation in various fraud schemes involving a total of $137 million in false billings for home health care, mental health services, occupational and physical therapy, DME and HIV infusion.  Two of these 59 defendants were originally charged in April 2012 but were indicted on additional charges today.  In one case, 10 defendants were charged for participating in a fraud scheme at Health Care Solutions Network, which led to approximately $63 million in fraudulent billing for community mental health center (CMHC) services.  Court documents allege that therapists at Health Care Solutions Network were instructed to alter notes and other medical documents to justify CMHC services for beneficiaries who did not need the services.

Seven individuals were charged today in Baton Rouge, La., for participating in a fraud scheme involving $225 million in false claims for CMHC services.  The case represents the largest CMHC-related scheme ever prosecuted by the Strike Force.  According to court documents, the defendants recruited beneficiaries from nursing homes and homeless shelters, some of whom were drug addicted or mentally ill, and provided them with no services or medically inappropriate services.

In Houston, nine individuals, including one doctor and one nurse, were charged today with fraud schemes involving a total of $16.4 million in false billings for home health care and ambulance services.  According to court documents, the owners and operators of four different ambulance companies billed Medicare for ambulance rides that were medically unnecessary.

Eight defendants, including two doctors, were charged in Los Angeles for their roles in schemes to defraud Medicare of approximately $14 million.  In one case, two individuals allegedly billed Medicare for more than $8 million in fraudulent billing for DME.

In Detroit, 22 defendants, including four licensed social workers, were charged for their roles in fraud schemes involving approximately $58 million in false claims for medically unnecessary services, including home health, psychotherapy and infusion therapy.

In Tampa, Fla., a pharmacist was charged with illegal diversion of controlled substances.  One defendant was charged last week in Chicago for his alleged role in a scheme to submit approximately $1 million in false billing to Medicare for psychotherapy services.

The Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,330 defendants who collectively have falsely billed Medicare for more than $4 billion.  In addition, the CMS, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The cases announced today are being prosecuted and investigated by Strike Force teams comprised of attorneys from the Fraud Section of the Justice Department’s Criminal Division and from the U.S. Attorneys’ Offices for the Southern District of Florida, the Eastern District of Michigan, the Southern District of Texas, the Central District of California, the Middle District of Louisiana, the Northern District of Illinois, and the Middle District of Florida, and agents from the FBI, HHS-OIG and state Medicaid Fraud Control Units.

An indictment is merely a charge and defendants are presumed innocent until proven guilty.

To learn more about HEAT, go to: www.stopmedicarefraud.gov.