We wrap up our look at Part II of the section in the Patient Protection and Affordable Care Act that creates the exchanges by reviewing the provisions on exchange financial integrity.
Every year, exchanges will have to submit to the federal Department of Health and Human Services reports on their activities, receipts and expenditures. HHS has the authority to investigate exchanges and examine their properties and records; exchanges must fully cooperate with investigations. In addition, exchanges are subject to annual audits by HHS.
HHS can rescind up to one percent of the payments due to the state for an exchange if it finds that the exchange or state has engaged in "serious misconduct" regarding compliance with PPACA requirements or in performing the activities required by the PPACA. The department can withhold the funds until the state or exchange takes adequate corrective actions. HHS must provide for the efficient and non-discriminatory administration of exchange activities. It must also implement measures and procedures that it determines are appropriate to reduce fraud and abuse in administration of the exchanges and that it has legal authority to perform.
By the end of 2018, the federal Government Accounting Office must conduct a study of exchange activities and people enrolled in exchange plans. The study must look at:
- The operations and administration of exchanges. This includes surveys and reports of exchange plans; plan data on enrollees through the exchanges and individuals who buy coverage outside the exchange; exchange expenses; claims and complaint data; and the manner in which exchanges meet their goals.
- Significant observations about the use and adoption of the exchanges
- Recommendations for improvements in exchange policies and operations, if appropriate
- A survey of the cost and affordability of exchange plans for small business owners and employees, including data on plan enrollees and purchasers of individual policies
- The number of physicians, by area and specialty, who are not accepting new patients enrolled in federal health insurance programs (Medicare, Medicaid, etc.), and how adequate provider networks are for those programs.
And that's all for Part II, Consumer Choices and Insurance Competition Through Health Benefit Exchanges.The next posts will attempt to answer the question: How much flexibility do states have when they create and run their exchanges? Given that the New York State Senate held a roundtable discussion (featuring IIABNY director Jack Smith) today, this discussion couldn't be more timely.
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