Last week, while many of us were digging out from one snowstorm and bracing for another, the United States Department of Health and Human Services (“HHS”) was keeping busy. HHS lawyers were preparing to defend a key regulation under the Affordable Care Act (“ACA”) before the U.S. Supreme Court, and HHS’ Office of Inspector General (“OIG”) released its Health Reform Oversight Plan (“the Oversight Plan”) for the 2015 fiscal year. The OIG is charged with protecting the integrity of HHS programs and the welfare of program beneficiaries. It carries out this mission through a variety of initiatives, including audits, investigations, evaluations and enforcement activities.
The Oversight Plan identifies the OIG’s four key strategic goals in overseeing ACA programs: (1) fighting fraud, waste and abuse; (2) promoting value, safety and quality; (3) securing the future; and (4) advancing excellence and innovation. With these goals in mind, the Oversight Plan highlights two key areas of focus for the OIG: health insurance marketplaces and other ACA-related reforms.
Health Insurance Marketplaces
The Oversight Plan suggests that the OIG will heavily emphasize federally facilitated and state health insurance marketplaces, with four key categories of initiatives. First, the OIG will examine whether taxpayer funds are being utilized for their intended purposes. Work in this area will include reviewing the accuracy and appropriateness of financial assistance payments (premium tax credits, advance premium tax credits, and cost sharing reductions), examining the Consumer Operated and Oriented Plan (“CO-OP”) Loan Program, and scrutinizing establishment and navigator grants and payments to federal contractors. The OIG may also undertake new initiatives to address payment system weaknesses and premium stabilization program payments.
Second, the OIG will review eligibility questions, particularly whether marketplace applicants are properly enrolled and matched to appropriate benefits. This work will include examining marketplace enrollment safeguards, eligibility verifications for premium tax credits and resolving inconsistencies in marketplace applicant data. Additional initiatives may focus on emerging issues, such as the marketplaces’ verification of employer information and eligibility for hardship waivers.
Third, the OIG will evaluate the extent to which HHS is managing marketplace programs effectively and efficiently. Reviews in this areas will include HHS’s management of the federally-facilitated marketplaces from ACA’s enactment in 2010 through the second open enrollment period, which ended on February 15, 2015, as well as oversight of federal contractors engaged in health reform programs. According to the Oversight Plan, future initiatives may include examining the redetermination process for consumers reenrolling in marketplaces and back-end administrative functions like financial reconciliation.
Finally, the health insurance marketplace reviews will evaluate the security of consumers’ personal information. These security focused initiatives will examine controls over personally identifiable information within both federally facilitated marketplaces and selected state-based marketplaces. Together with law enforcement agencies, the OIG will continue monitoring cybersecurity threats to marketplaces and investigating consumer fraud.
Health Reform in Other HHS Programs
Beyond its marketplace emphasis, the OIG will also devote significant resources to other health reform programs. The OIG’s other work falls into four categories: Medicaid expansion and services, Medicare payment and delivery reform, Medicare and Medicaid program integrity and public health programs.
With respect to Medicaid expansion, the OIG will continue to review states’ assignments of Medicaid enrollees to the correct federal matching rate and the Community First Choice and Balancing Incentive Programs. The OIG also plans to scrutinize the accuracy of states’ eligibility determinations.
Likewise, the OIG will continue to monitor Medicare payment reform efforts, including the transition to value-based payment systems, care delivery coordination efforts, reforms to the fee-for-service model and shared savings. Currently, the OIG is reviewing federal Medicaid reimbursement for hospital-acquired conditions and the Centers for Medicare & Medicaid Services’ (“CMS”) administration of the pioneer accountable care organization program. The OIG anticipates that future work in this area will include reviewing the effectiveness of linking payments to quality measures and accountable care organizations, medical homes and bundled payment models.
Regarding program integrity, the OIG will examine enhanced provider screening systems, provider payment suspensions, provider terminations and managed care encounter data. The OIG may also begin monitoring CMS’ open payments database and other transparency initiatives.
Finally, the OIG anticipates examining certain public health programs, including the Community Health Centers Fund, the Prevention and Public Health Fund and other ACA grant programs.
Access the complete Oversight Plan here.