Trump ad­min­is­tra­tion backs off pe­nal­iz­ing ex­change plans for not au­dit­ing risk-ad­just­ment pro­gram

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Some in­sur­ers say they’re more likely to stay on the in­sur­ance ex­changes now that a penalty against fail­ing to re­port the num­ber of se­verely ill pa­tients they have has been lifted.

The Trump ad­min­is­tra­tion last week said it would not en­force an Af­ford­able Care Act pro­vi­sion meant to pre­vent in­sur­ers from cherry-pick­ing the health­i­est mem­bers. The law’s risk-ad­just­ment pro­gram al­lowed com­pa­nies that cover peo­ple with com­plex health con­di­tions to re­ceive money from in­sur­ers that have gen­er­ally health­ier mem­bers.

“We think an ad­di­tional pilot year with­out fi­nan­cial penal­ties will ul­ti­mately help is­suers bet­ter op­er­a­tional- ize the pro­gram—and will elim­i­nate yet another area of fi­nan­cial un­cer­tainty for the com­ing year,” said Meg Mur­ray, CEO of the As­so­ci­a­tion for Com­mu­nity Af­fil­i­ated Plans. Nonethe­less, in­sur­ance gi­ant Aetna plans to fully with­draw from the ex­change mar­ket in 2018.

In 2015, Blue Shield of Cal­i­for­nia re­ceived $182 mil­lion in pay­ments un­der the risk-ad­just­ment pro­gram. Health Net of Cal­i­for­nia got $126 mil­lion and Blue Cross and Blue Shield of Florida got $369 mil­lion, fed­eral data show.

The law re­quired third-party au­di­tors and HHS to con­firm that plans re­ceiv­ing risk-ad­just­ment pay­ments do in­deed have sicker pa­tients. HHS has been col­lect­ing data from the plans but hasn’t held them ac­count­able for dis­crep­an­cies.

The CMS, in a lit­tle-no­ticed memo re­leased May 3, said it would de­lay penal­ties for a year, un­til 2018.

That al­lows plans to in­cor­po­rate key pro­cesses, pro­ce­dures and tech­ni­cal changes, said Jef­fery Drozda, CEO of the Louisiana As­so­ci­a­tion of Health Plans.

Ceci Con­nolly, CEO of the Al­liance of Com­mu­nity Health Plans, said some in­sur­ers don’t have fed­eral data on the ac­cu­racy of their claims. “It hasn’t been pos­si­ble to re­view lessons learned and strengthen the col­lec­tion and re­port­ing of di­ag­noses for risk ad­just­ment,” she said. “That’s crit­i­cal, given the im­por­tance of ac­cu­rate di­ag­no­sis cod­ing in de­ter­min­ing pay­ments and the ben­e­fit pack­ages that plans can of­fer to en­rollees.”

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