THE AFFORDABLE CARE ACT:SYSTEMS & REPORTING

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OVERVIEW

• Systems• Data Validation• Program Integrity• Financial Integrity• Prevention of Fraud, Waste, and Abuse• Program Transparency• Reporting Requirements• Key Dates

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SYSTEMS

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SYSTEMS

• Systems include both policies and procedures and information technology systems (e.g., a database or a website) put in place to accomplish a specific task or requirement

• Systems should be established to support:o Eligibility and Enrollmento Data Collecting and Processingo Financial Reporting o Electronic Health Records (EHRs) o Privacy and Security Standards

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SYSTEMS: ELIGIBILITY AND ENROLLMENT

• Exchanges must have a system in place that will both determine eligibility and enroll applicants into the chosen QHP

• The system must:o Have a web portalo Be streamlined for simplicityo Determine eligibility for government sponsored

healthcare/tax benefitso Communicate with other systems, such as CMS and IRS

databases

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SYSTEMS:DATA COLLECTING AND PROCESSING

• ACA §4302 allows for data collection in order to determine health care disparities and demographicso Race and ethnicity, gender, primary language, and disability

status are the types of data collectedo Data is collected to ensure that minorities and underserved

communities have access to healthcare

• A work group consisting of HHS, OMB, and the Census Bureau is helping states to develop standards for data collection and processing

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SYSTEMS:FINANCIAL REPORTING

• In order to determine if an applicant is eligible for tax credits, data must be provided to the Exchange

• Data submitted can include:o Name, DOB, SSN

o Household size, Income

o Employer coverage

o EIN, # of employees, amounts paid for employee

• Exchanges will submit financial and demographic data electronically

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SYSTEMS:FINANCIAL REPORTING FOR

TAX CREDITS

Small Business Health Care Tax Credito Employers report to IRS number of employees, employee

roster, average annual salary paid, and the amount paid for employee health coverage

Health Insurance Premium Tax Credito Individuals need to report income information, family size,

and information on changes in circumstances

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SYSTEMS:ELECTRONIC HEALTH RECORDS

(EHRS)

• EHRs are digital health records that allow medical providers (i.e., physicians and hospitals) to electronically send and receive patient information to/from other medical providers

• EHRs must follow the Health Insurance Portability and Accountability Act (HIPAA), Protected Health Information (PHI), and Personally Identifiable Information (PII) standards for protecting patient’s medical information

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SYSTEMS:PRIVACY AND SECURITY STANDARDS

• Exchanges are required to follow applicable HIPAA, PHI, and PII security laws; and

• ACA §1104 administrative standards, which include :o Standards and operating rules for EFT and remittance

advice,o A unique identifier for health plans, o A standard for claims attachments, ando Requirements that health plans certify compliance with all

HIPAA standards and operating rules

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DATA VALIDATION

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DATA VALIDATION: APPLICANT

Data validation for individual applicants by Exchange:

• Basic Information Verification ensure all fields are complete and data is valid

• Citizenship Verification applicant’s citizenship status is compared to Social Security Administration records or, in some instances the Department of Homeland Security records

• Incarceration Status Verification SSN will be used to verify incarceration status

• Income Verification income data will be compared to Internal Revenue Service records for tax credit/government-based healthcare eligibility

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• The proposed federal data services hub is expected to have verification services operational for the open enrollment period beginning on October 1, 2013.

• The Department of Health and Human Services (HHS) has contracted with Quality Software Services, Inc. to “build and support the operations of a federal data service hub that will provide data verification to support eligibility processes for all Exchanges, Medicaid, and CHIP.”

DATA VALIDATION: APPLICANT

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DATA VALIDATION:EMPLOYER-SPONSORED COVERAGE

Data validation for employer-sponsored coverage by Exchange:

• Employee Information compared to either the employer provided information or to a governmental agency

• Employer Information compared to governmental agencies, such as the Department of the Treasury, Department of Labor, and the Social Security Administration

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• HHS expects the infrastructure for an authoritative data source to be in place by 2016.

• In the interim, for the plan years 2014-2015, HHS is seeking ideas from various stakeholders (e.g., employers, the health care industry, and other government agencies) on this topic.

• Through the federal rulemaking process there have been several options proposed for the interim process for employment verification.

DATA VALIDATION:EMPLOYER-SPONSORED COVERAGE

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DATA VALIDATION: RISK ADJUSTMENT

• HHS proposed risk adjustment data validation process will include the following steps:

1. Sample Selection2. Initial Validation Audit3. Second Validation Audit4. Error Estimation5. Appeals6. Payment Adjustments

• After data validation, the state/HHS will be able to adjust the average actuarial risk of each plan or payments/charges based on risk changes

Please refer to our

previous piece on Risk and

Reinsurance for more

information on the Risk Adjustment Programs.

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REPORTING REQUIREMENTS

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REPORTING REQUIREMENTS: ENROLLMENT DATA

Exchanges and health plan issuers must report enrollment data for each of the following to HHS:

• Individual applicants (unemployed or enrolling in insurance not through an employer)o Name, address, household income, household size ,

proof of citizenship/immigration status

• Employerso Employer name, address and contact information o Employee roster and number of employees

• Employeeso Name, address, contact information, DOB, dependent

information

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Issuers in each state that offer the three largest health insurance products must submit the following information to HHS:• Information that identifies their individual health

plans• Descriptive data of the health plans• Information on any treatment limitations• Information about plan drug coverage• Information about plan enrollment

REPORTING REQUIREMENTS: ISSUER DATA

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REPORTING REQUIREMENTS: FINANCIAL DATA

ACA §1313 – Financial integrity• Exchanges must account for expenditures and all activities and

submit annual reports to HHS• HHS audits Exchanges annually• GAO Comptroller General can conduct studies of Exchange

operations

ACA §10109 – Development of standards for financial and administrative transactions

• Standard application process• Greater transparency for claim edits• Standardized forms for required financial audits• Standards on whether timeliness of payment rules should be

published by health plans

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KEY DATES

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KEY DATES: SYSTEMS & REPORTING

 

DATE EVENT April 1 Beginning in 2012, drug manufacturers/distributors are required

to send annual reports to HHS on drug sample requests and distributions from the previous year.

June 30 Beginning in 2012, annual reports from PBM due to HHS.

March 31, 2013 and on the 90th day of every year following

Annual reports on physician payments due to HHS from manufacturers for the previous year.

December 31, 2013 Health plans must certify that data and information systems are in compliance with applicable standards and operating rules for:• Health plan eligibility,• Health claim status,• EFTs, and• Health care payment and remittance advice.

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DATE EVENT January 1, 2014 Operating rules and standards for EFT and remittance advice in

effect .

January 31 Beginning 2015, employers are to annually file a report with the IRS certifying employee enrollment in minimum essential coverage through an employer-sponsored plan for the previous year.

December 31, 2015 Health plans must certify data and information systems are in compliance with applicable standards and operating rules for: Health claims or equivalent encounter information, Enrollment and disenrollment in a health plan, Health plan premium payments, Referral certification and authorization, and Health claims attachments .

January 1, 2016 Operating rules for all health plan certification as described above are in effect.

KEY DATES: SYSTEMS & REPORTING

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REED & ASSOCIATES, CPAS

For more information on Reed & Associates, CPAs please contact us at:

inquire@reedassociatescpas.com

Phone: 860-395-1996

Or visit our website:

reedassociatescpas.com

Quality. Integrity. Experience.