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Healthcare Roundup

Healthcare Roundup

This week,Strategic Insights is updating you on issues covered in past blogs.

Risk Corridor Controversy Continues

Last week we told you the Centers for Medicare and Medicaid Services (CMS) was looking for ways to reimburse plans for a massive shortfall and settle lawsuits for plan claims related to the transitional Exchange risk corridor payment program from 2014. Many Exchange plans are owed tens or hundreds of millions of dollars each from the federal government. This week, the Department of Justice (DOJ) asked a federal judge to rule against the plan’s petitions because CMS could make up the money over the three-year horizon of the program and it technically does not really owe the money due to a lack of an appropriation.

CMS’ opposition to payment in the legal brief – however oblique – was not entirely unexpected, especially given a mounting investigation by Congress of the backroom communication between plans and CMS on a settlement. It, too, could be part of a leverage game with disgruntled insurers.

A settlement is not entirely out of the question. Publication of 2015 plan claims and expected reimbursement has so far been delayed. CMS has said payments into the fund will be well short of expected claims reimbursements and, at any rate, monies paid for 2015 will go to help cover the 2014 shortfall.

In essence, without a settlement, the shortfall is only expected to grow, compounding plans’ financial stress and CMS’ headache. The congressional GOP majority has technically already blocked appropriations from making up risk corridor shortfalls and is now plotting to bar the settlement as well.

It all seems unfair. Whatever your views of Obamacare, plans participated with the commitment of the stabilization monies.

Feds to Pick Health Plans for Displaced Enrollees

Rattled by the major exits or retrenchment of many health plans in the Affordable Care Act Exchanges, CMS is looking for every way to ensure that frustrated Americans do not give up on Obamacare and fail to look for a new plan if their old plan is no longer available. The administration will send notices to people of the alternative plan they will be enrolled in and the new plan may even reach out to the member. CMS, however, says no one will be forcibly enrolled in a plan. A special enrollment period will be granted for those impacted, even after the open enrollment period ends.

The plan has gotten mixed reviews. Some believe it will help people transition. Others fear confusion as well as dissatisfaction because coverage in the new plan could be different than the old.

Americans Missing Healthcare Credits

The Department of Health and Human Services (HHS) estimates about 2.5 million Americans enrolled in the Exchanges are missing out on subsidies they may be eligible for. Subsidies are only an entitlement if someone goes through www.healthcare.gov rather than buying direct from a plan. HHS has often touted that Obamacare costs have been well under budget. This is one reason. Unless revamped, the cost will not stay reasonable for long, for a whole host of reasons.

Bill Clinton on Health Law Dichotomy: “It’s the Craziest Thing in the World”

Foot-in-mouth disease has been rampant this election season, affecting both major party candidates. This past week, it also affected former President Bill Clinton. As with much of the criticism this election season, it seems to be taken a bit out of context. Overall, the President praised the fact the law has covered millions of Americans. But he rightfully noted there are haves and have nots with the Exchange. Many receive exceedingly generous subsidies while others (Clinton noted small businesses and those who made just a little too much to obtain a subsidy) are still struggling to obtain and maintain insurance.

As we have noted for years now, Clinton is not wrong. We have argued that subsidies for the poorest are too generous and work against taking personal responsibility. Those in middle income ranges get too little and must pay in almost 10 percent of their incomes before any subsidy kicks in.

House GOP Wants End to Bundled Payment Reforms

Much of the House GOP in Congress has written CMS to ask that the bundled payment program in Medicare fee-for-service be shut down over quality of care concerns and because such programs overstep the agency’s scope. At issue is opposition by providers to the joint replacement and cardiac bundled payment pilots.

The move is a bit cynical. It is hard to argue that experimentation in the Medicare fee-for-service world should be ignored when about two-thirds of beneficiaries are still in the traditional program. Forcing better collaboration between providers and hospitals in high-cost areas is essential, along with promoting quality outcomes over the transaction-based system.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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