Health Insurance Exchange Marketplace Opens Tomorrow

Consumers  and Small Business Owners can sign up for health plans for the first time, renew or change their plans for 2015 on HealthCare.gov [or https://www.nevadahealthlink.com/ in Nevada]; more plans are available this year

HealthcareInsuranceStarting tomorrow, consumers can sign up for 2015 health insurance plans through HealthCare.gov, the call center, or in-person assistance. With more issuers offering coverage through the Health Insurance Marketplace this year, the consumers will find more options for themselves and their families.

“When Open Enrollment begins tomorrow, consumers who are renewing their coverage or signing up for the first time will have an opportunity to obtain quality health coverage at a price they can afford,” said Health and Human Services Secretary Sylvia M. Burwell. “Whether consumers visit the simpler, faster and more intuitive HealthCare.gov or contact the call center, they’re going to find more choices and competitive prices.”

The Health Insurance Marketplace is a simpler way to purchase health insurance for Americans and their families. Consumers can go online to find and compare options, see if they qualify for lower costs, and select coverage that best meets their needs and budget. About 85 percent of those who signed up last year through the Marketplace received financial assistance. Coverage begins as early as January 1, 2015 for people enrolling by December 15, 2014. Tomorrow, the Centers for Medicare & Medicaid Services (CMS) is launching an education and outreach campaign in communities nationwide to drive both the uninsured and current enrollees to enroll in coverage or renew their coverage. Enrollment events will take place in local communities including in public libraries, churches, festivals, sports events, and community meetings.

“Tomorrow marks the beginning of an intense open enrollment and public education campaign for the Marketplace,” said CMS Administrator Marilyn Tavenner. “We want consumers to visit the Marketplace, compare their options, see if they qualify for lower costs, and reenroll or get new coverage that best meets their needs and budget.”

CMS has worked to improve the consumer experience by making the application process easier. A window shopping tool allows consumers to answer a few simple questions, such as location and family size, in order to compare plans and get an estimate on how much financial assistance they may qualify for, without needing a log-in or submitting an application.

For most consumers who are renewing coverage, up to 90 percent of their application will be pre-filled based on last year’s application. And a new streamlined application reduces the number of screens to 16 with fewer clicks to navigate through the questions for most consumers signing up for the first time. Last year, consumers went through 76 screens to sign up for coverage. This year, along with a simpler, faster application, consumers can shop and enroll on a smartphone, tablet, computer, or by calling the call center or with in-person assistance.

Tomorrow, Secretary Burwell will participate in an enrollment event at the Evergreen Health Center in Manassas, Virginia with local consumers and Certified Application Counselors who are helping consumers enroll.

Open Enrollment for the Health Insurance Marketplace begins tomorrow, Nov. 15, 2014, and runs through Feb. 15, 2015. Consumers should visit HealthCare.gov to review and compare health plan options and find out if they are eligible for financial assistance, which can help pay monthly premiums and reduce out-of-pocket costs when receiving services. All consumers shopping for health insurance coverage for 2015— even those who currently have coverage through the Marketplace — should enroll or re-enroll between November 15 and December 15 in order to have coverage effective on Jan. 1, 2015.

A number of different resources are available to help consumers find Marketplace coverage. They can get more information through HealthCare.gov or CuidadoDeSalud.gov. Consumers can find local help at: Localhelp.healthcare.gov or call the Federally-facilitated Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325. Assistance is available in 150 languages. The call is free.

The Marketplace includes a Small Business Health Option Program (SHOP), designed to give small businesses new health insurance options and a simpler way to cover their employees. The SHOP is available to small employers with 50 or fewer full-time equivalent employees. Starting tomorrow, November 15, 2014, the SHOP Marketplace will allow qualifying employers to find, compare, purchase, and enroll in 2015 SHOP health and dental coverage entirely online through HealthCare.gov. Employees will be able to view offers of insurance from their employer and enroll online through HealthCare.gov. Small businesses and their employees can get help from the toll-free SHOP Marketplace call center at 1-800-706-7893 or for TTY, call 711. The hours are Monday through Friday, 9 a.m. to 7 p.m. EST.

To sign up for individual and family coverage, visit: https://www.healthcare.gov/apply-and-enroll/

To sign up for small business coverage, visit: https://www.healthcare.gov/small-businesses/

For more information about Health Insurance Marketplaces, visit: www.healthcare.gov/marketplace


Note: All HHS press releases, fact sheets and other news materials are available at http://www.hhs.gov/news.

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Government Teams Recovered $4.3B in FY2013 and $19.2B over the Last 5 Years

Attorney General Eric Holder and HHS Secretary Kathleen Sebelius today released the annual Health Care Fraud and Abuse Control (HCFAC) Program report showing that for every dollar spent on health care-related fraud and abuse investigations through this and other programs in the last three years, the government recovered $8.10.  This is the highest three-year average return on investment in the 17-year history of the HCFAC Program.

810The government’s health care fraud prevention and enforcement efforts recovered a record-breaking $4.3 billion in taxpayer dollars in Fiscal Year (FY) 2013, up from $4.2 billion in FY 2012, from individuals and companies who attempted to defraud federal health programs serving seniors or who sought payments from taxpayers to which they were not entitled.  Over the last five years, the administration’s enforcement efforts have recovered $19.2 billion, up from $9.4 billion over the prior five-year period.  Since the inception of the program in1997, the HCFAC Program has returned more than $25.9 billion to the Medicare Trust Funds and treasury.

These recoveries, released today in the annual HCFAC Program report, demonstrate President Obama’s commitment to making the elimination of fraud, waste and abuse, particularly in health care, a top priority for the administration.  This is the fifth consecutive year that the program has increased recoveries over the past year, climbing from $2 billion in FY 2008 to over $4 billion every year since FY 2011.

The success of this joint Department of Justice and HHS effort was made possible in part by the Health Care Fraud Prevention and Enforcement Action Team (HEAT), created in 2009 to prevent fraud, waste and abuse in Medicare and Medicaid and to crack down on individuals and entities that are abusing the system and costing American taxpayers billions of dollars.

“With these extraordinary recoveries, and the record-high rate of return on investment we’ve achieved on our comprehensive health care fraud enforcement efforts, we’re sending a strong message to those who would take advantage of their fellow citizens, target vulnerable populations, and commit fraud on federal health care programs,” said Attorney General Eric Holder.  “Thanks to initiatives like HEAT, our work to combat fraud has never been more cooperative or more effective.  And our unprecedented commitment to holding criminals accountable, and securing remarkable results for American taxpayers, is paying dividends.”

“These impressive recoveries for the American taxpayer are just one aspect of the comprehensive anti-fraud strategy we have implemented since the passage of the Affordable Care Act,” said HHS Secretary Sebelius.  “We’ve cracked down on tens of thousands health care providers suspected of Medicare fraud. New enrollment screening techniques are proving effective in preventing high risk providers from getting into the system, and the new computer analytics system that detects and stops fraudulent billing before money ever goes out the door is accomplishing positive results – all of which are adding to savings for the Medicare Trust Fund.”

The new authorities under the Affordable Care Act granted to HHS and the Centers for Medicare & Medicaid Services (CMS) were instrumental in clamping down on fraudulent activity in health care.  In FY 2013, CMS announced the first use of its temporary moratoria authority granted by the Affordable Care Act.  The action stopped enrollment of new home health or ambulance enrollments in three fraud hot spots around the country, allowing CMS and its law enforcement partners to remove bad actors from the program while blocking provider entry or re-entry into these already over-supplied markets.

The Justice Department and HHS have improved their coordination through HEAT and are currently operating Medicare Fraud Strike Force teams in nine areas across the country. The strike force teams use advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes as well as chronic fraud by criminals masquerading as health care providers or suppliers. The Justice Department’s enforcement of the civil False Claims Act and the Federal Food, Drug and Cosmetic Act has produced similar record-breaking results.  These combined efforts coordinated under HEAT have expanded local partnerships and helped educate Medicare beneficiaries about how to protect themselves against fraud.

In Fiscal Year 2013, the strike force secured records in the number of cases filed (137), individuals charged (345), guilty pleas secured (234) and jury trial convictions (46). Beyond these remarkable results, the defendants who were charged and sentenced are facing significant time in prison – an average of 52 months in prison for those sentenced in FY 2013, and an average of 47 months in prison for those sentenced since 2007.

In FY 2013, the Justice Department opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants, and a total of 718 defendants were convicted of health care fraud-related crimes during the year.  The department also opened 1,083 new civil health care fraud investigations.

The strike force coordinated a takedown in May 2013 that resulted in charges by eight strike force cities against 89 individuals, including doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $223 million in false billings. As a part of the May 2013 takedown, HHS also suspended or took other administrative action against 18 providers using authority under the health care law to suspend payments until an investigation is complete.

In FY 2013, the strike force secured records in the number of cases filed (137), individuals charged (345), guilty pleas secured (234) and jury trial convictions (48). Beyond these remarkable results, the defendants who were charged and sentenced are facing significant time in prison – an average of 52 months in prison for those sentenced in FY 2013, and an average of 47 months in prison for those sentenced since 2007.

In March 2011, CMS began an ambitious project to revalidate all 1.5 million Medicare enrolled providers and suppliers under the Affordable Care Act screening requirements. As of September 2013, more than 535,000 providers were subject to the new screening requirements and over 225,000 lost the ability to bill Medicare due to the Affordable Care Act requirements and other proactive initiatives.  Since the Affordable Care Act, CMS has also revoked 14,663 providers and suppliers’ ability to bill the Medicare program. These providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules.

HHS and the Justice Department are leading historic efforts with the private sector to bring innovation to the fight against health care fraud. In addition to real-time data and information exchanges with the private sector, CMS’ Program Integrity Command Center worked with the HHS Office of the Inspector General and the FBI to conduct 93 missions to detect, investigate, and reduce improper payments in FY 2013.

From May 2013 through August 2013, CMS led an outreach and education campaign targeted to specific communities where Medicare fraud is more prevalent.  This multimedia campaign included national television, radio, and print outreach and resulted in an increased awareness of how to detect and report Medicare fraud.

To read today’s report visit http://oig.hhs.gov/publications/docs/hcfac/FY2013-hcfac.pdf

For previous years’ reports visit https://oig.hhs.gov/reports-and-publications/hcfac/index.asp

For more information on the joint DOJ-HHS Strike Force activities, visit: www.StopMedicareFraud.gov/.

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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“Profit-Motive” Is Negatively Impacting Your Healthcare: Medicare Provider Charge Data

As part of the Obama administration’s work to make our health care system more affordable and accountable, data are being released by HHS (Health & Human Services) that show significant variation across the country, even within communities as to what hospitals charge for common inpatient services.

“Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city,” Secretary Sebelius said. “This data and new data centers will help fill that gap.”  For example,

  • In Dallas, Las Colinas Medical Center billed Medicare an average of $160,832 for a lower joint replacement. The price was $42,632 five miles away, at Baylor Medical Center.
  • Average inpatient charges for services for a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.
  • Average inpatient hospital charges to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.
  • Ventilator: $115,00 George Washington University vs. $53,000 at Providence (just 5.4 miles apart)
  • Lower limb replacement: $117,000 at Richmond CJW Medical Center vs. 25,600 at Winchester Medical Center
  • Pneumonia: $124,051 in Philadelphia vs. $5,093 in Water Valley, Mississippi.

According to Ron Pollack, executive director of Families USA, hospital pricing is “the craziest of crazy quilts.” He went on to say, “It is absurd — and, indeed, unconscionable — that the people least capable of paying for their hospital care bear the largest, and often unaffordable, cost burdens.”

Medicare has begun paying providers based on quality rather than just the quantity of services they furnish by implementing new programs, such as value-based purchasing and re-admissions reductions.  HHS awarded $170 million to states to enhance their rate review programs, and since the passage of the Affordable Care Act (ACA), the proportion of insurance company requests for double-digit rate increases fell from 75 percent in 2010 to 14 percent so far in 2013.

The ACA also makes available many tools to help ensure consumers, Medicare, and other payers get the best value for their health care dollar.  To make data from these tools useful to consumers, HHS is also providing funding  to data centers to collect, analyze, and publish health pricing and medical claims reimbursement data.  The data centers’ work helps consumers better understand the comparative price of procedures in a given region or for a specific health insurer or service setting. Businesses and consumers alike can use these data to drive decision-making and reward cost-effective provision of care.

Data are available in Microsoft Excel (.xlsx) format and comma-separated values (.csv) format.

Inpatient Charge Data, FY2011, Microsoft Excel version
Inpatient Charge Data, FY2011, Comma Separated Values (CSV) version

Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service. The Total Payment amount includes a Medicare Severity Diagnosis Related Group (MS-DRG) amount, bill total per diem, beneficiary primary payer claim payment amount, beneficiary Part A coinsurance amount, beneficiary deductible amount, beneficiary blood deducible amount and DRG outlier amount.

Data provided by CMS (Centers for Medicare/Medicaid Services) include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the MS-DRG for FY2011.

DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges. Average charges and average Medicare payments are calculated at the individual hospital level. Users will be able to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.

There is some debate about how much patients, insurance providers and the government actually end up paying. “It’s true that Medicare and a lot of private insurers never pay the full charge,” said assistant professor at the University of California at San Francisco Medical School, Renee Hsia, “You have a lot of private insurance companies where the consumer pays a portion of the charge. But, for uninsured patients, they face the full bill. In that sense, the price matters.”

To view the new hospital dataset, please go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html.

To access the funding opportunity announcement, visit: http://www.grants.gov, and search for CFDA # 93.511.

For more information on HHS efforts to build a health care system that will ensure quality care, please see the fact sheet “Lower Costs, Better Care: Reforming Our Health Care Delivery System,” athttp://www.cms.gov/apps/media/press/factsheet.asp?Counter=4550.

To read a fact sheet about the Medicare data showing variation in hospital charges, please see:http://www.cms.gov/apps/media/fact_sheets.asp.

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New Support for Consumer-driven Non-profit Health Plan in Nevada

— CMS awards loan to Hospitality Health Co-Op —

The Affordable Care Act creates a new type of nonprofit health insurer, called a Consumer Oriented and Operated Plan, or “CO-OP.”  CO-OPs are directed by their customers and designed to offer individuals and small businesses more affordable, consumer-friendly and high quality health insurance options. 

Starting January 1, 2014, CO-OPs, will be able to offer health plans through the new, competitive health care marketplaces in each state, called the Affordable Insurance Exchanges.  In addition to offering health plans through an Exchange, CO-OPs may also offer health plans outside of an Exchange.

CO-OP loans are only made to private, non-profit entities that demonstrate a high probability of financial viability. All CO-OPs receiving loans were selected by CMS on a competitive basis based on external independent review by a multi-disciplinary team. Only when CO-OPs meet or exceed developmental milestones are funds allowed to be incrementally drawn down.

The Centers for Medicare & Medicaid Services (CMS) recently awarded a loan to Hospitality Health CO-OP in Nevada to launch a new private non-profit, consumer-governed health insurance company, called a Consumer Operated and Oriented Plan (CO-OP).

Hospitality Health CO-OP
Service Area: Nevada
Award Amount: $65,925,396
Award Date: May 18, 2012

Hospitality Health CO-OP is sponsored by the Culinary Health Fund, its national parent Unite HERE Health, and the Health Services Coalition. Hospitality Health CO-OP will operate for everyone in the Exchanges and the individual and small group markets. Hospitality Health CO-OP plans to provide health insurance coverage statewide.

Created by the Affordable Care Act, the CO-OP Program encourages eligible groups to create new, innovative and consumer-responsive health insurance companies to increase competition in the individual and small business markets. 

“CO-OPs will promote competition and give consumers more health insurance choices,” said Marilyn Tavenner, CMS acting administrator.  “These new private non-profit insurers will be run by consumers and are designed to offer individuals and small businesses more affordable consumer-friendly and high quality health insurance plans.”

In addition to giving consumers more choices and improving competition in their states, as consumer-run insurers, CO-OPs will operate differently from traditional insurance companies.  More than half of the Board of Directors must be the customers or members of the CO-OP, and all directors must be elected by a majority vote of the members, improving accountability and transparency.  Under the Affordable Care Act, profits gained by a CO-OP must go directly back to their enrollees, to be used to lower premiums, expand benefits, or improve quality.

To ensure CO-OPs are truly new entities, the health care reform law prohibits any state-licensed health insurance company that existed on July 16, 2009, from qualifying for the CO-OP program.

CMS will closely monitor CO-OPs to ensure they are meeting program goals.  To ensure strong financial management, CO-OPs are required to submit quarterly financial statements, including cash flow and enrollment data, receive site visits and undergo annual external audits.  This monitoring is concurrent with the financial and operational oversight by state insurance regulators.  The CO-OPs are required to meet state and federal standards for qualified health plans to sell coverage through the Exchanges and the State’s Small Business Health Option Programs.

The CO-OP program offers low-interest loans to eligible nonprofit groups to help set up and maintain these issuers.  To date, a total of 12 non-profits offering coverage in 12 states have been awarded $982,472,104.

For more information on the CO-OP program and recent awardees, please visit http://www.healthcare.gov/news/factsheets/2012/02/coops02212012a.html. For more information on CO-OPs, including what federal loans are available, who can apply and licensing requirements, please visit:  http://cciio.cms.gov/resources/factsheets/coop_final_rule.html