United States: Weekly Washington Healthcare Update - December 8, 2014

This Week: Energy and Commerce Health Subcommittee Examines Future of Children's Health Insurance Program (CHIP)... Illinois House Withholds Vote on State-Based Health Insurance Exchange... CMS Releases Proposed Rule on ACA Benefit and Payment Parameters for 2016

1. CONGRESS

House

Health Subcommittee Hearing Examines Future of CHIP

On Dec. 3, the Energy and Commerce Subcommittee on Health held a hearing entitled "The Future of the Children's Health Insurance Program" in which the subcommittee heard testimony on key issues that Congress should evaluate as it considers the future of the State Children's Health Insurance Program (CHIP), including the current status of the program and how the President's health care law has affected it. Funding for CHIP is set to end after fiscal year 2015. CHIP was designed to work in coordination with Medicaid to provide health coverage to low-income children. Among other changes, the ACA further expanded the options for some children in low-income families with incomes at or above CHIP eligibility levels by offering subsidized coverage for insurance purchased through health insurance exchanges.

For more information, or to view the hearing, please visit energycommerce.house.gov.

House Passes Bill Aimed to Assist Individuals with Disabilities

This week, the House passed, by a vote of 404-17, H.R. 647, the Achieving a Better Life Experience (ABLE) Act of 2014. Under the legislation, individuals with ABLE accounts could maintain eligibility for means-tested benefit programs such as SSI and Medicaid. Specifically, the bill would exempt the first $100,000 in ABLE account balances from being counted toward the SSI program's $2,000 individual resource limit; however, account distributions for housing expenses would be counted as income for SSI purposes. Assuming the individual has no other assets, if the balance of an individual's ABLE account exceeds $102,000, the individual would be suspended from eligibility for SSI benefits but would remain eligible for Medicaid. States would be required to recoup certain expenses through Medicaid upon the death of the individual. According to the Joint Committee on Taxation (JCT) and the Congressional Budget Office (CBO), Sections 102 and 103 of the legislation would reduce revenues by $898 million over 2015-2024 and would increase outlays by $1.153 billion over 2015-2024. In order to offset this cost, the bill included several "pay-for" measures, such as a one-year delay in implementation of the oral-only policy under Medicare ESRD prospective payment system, and accelerating the application of relative value targets for misvalued services in the Medicare physician fee schedule. The bill moves to the Senate where 70 members have cosponsored similar legislation.

Bipartisan Medicare Anti-Fraud Bill Introduced in the House

On Dec. 2, the House Ways and Means Health Subcommittee Chairman Kevin Brady (R-TX) and the full committee's Ranking Member Jim McDermott (D-WA) introduced a wide-ranging Medicare anti-fraud bill, Protecting the Integrity of Medicare Act (H.R. 5780), that would strip Social Security numbers from Medicare cards, increase education and outreach efforts from Medicare Administrative Contractors (MAC) to providers, broaden the scope of who can sign off on durable medical equipment face-to-face requirements, and extend the MAC contracts to 10 years (from 5 years); moreover the bill also sets up a beneficiary lock-in program for high-risk drugs (the bill would limit at-risk Medicare Part D beneficiaries to one or more physicians and one or more pharmacies for the prescription and dispensing of opioids and similar prescription drugs) and requires home health agencies to have a surety bond worth at least $50,000. While a draft of the bill was released in August, the newly crafted bill scraps several Medicaid program integrity provisions that were previously included in the discussion draft; the sponsors hope the bill will pass by the end of the year.

Additional anti-fraud provisions included in the bill:

• Increasing incentive payments for participants in the Senior Medicare Patrol;
• Requiring prescribers to use valid national provider identifiers on all pharmacy claims (the new cards would use a different beneficiary identifier that would be convertible to a Social Security number within the Department of Health and Human Services); and
• Giving Medicare beneficiaries the option of receiving their Medicare summary notice electronically.

A press release accompanying the legislation can be found here.

Upcoming Health Subcommittee Hearing to Examine Health Spending Priorities

On Dec. 9, the Energy and Commerce Subcommittee on Health will hold a hearing entitled "Setting Fiscal Priorities." The subcommittee will hear testimony on key policy decisions the committee may face in the 114th Congress as it seeks to adopt reforms that put the Federal budget on a more sustainable trajectory by curbing unrestrained spending in Federal health care programs.

For more information, or to view the hearing, please visit energycommerce.house.gov.

Upcoming Health Subcommittee Hearing Will Explore GMO Regulations

On Dec. 10, the Energy and Commerce Subcommittee on Health will hold a hearing entitled "Examining FDA's Role in the Regulation of Genetically Modified Food Ingredients," in which the committee will examine the Food and Drug Administration's role in regulating genetically modified ingredients in our nation's food supply. Members will hear from the FDA, outside experts and interested stakeholders about the agency's current review process for our food ingredients. The subcommittee will also discuss related bipartisan legislation, H.R. 4432, the Safe and Accurate Food Labeling Act, which would amend the Federal Food, Drug, and Cosmetic Act with respect to food produced from, containing or consisting of a bioengineered organism, the labeling of natural foods.

Senate

Bipartisan Bill Aimed at Improving Innovation in Health IT

On Dec. 4, Sens. Bennet (D-CO) and Hatch (R-UT) introduced a bill to cut red tape at the Food and Drug Administration (FDA) and help boost innovation in health IT. The Medical Electronic Data Technology Enhancement for Consumers Health (MEDTECH) Act would exempt low-risk medical software and mobile apps from FDA regulation and provide greater certainty regarding what software will be regulated by the agency to protect consumers. The MEDTECH Act takes a risk-based approach and builds upon a Food and Drug Administration Safety Innovation Act Workgroup report released earlier this year. The report was commissioned by Bennet and Hatch through an amendment to the 2012 FDA reform law. Specifically, the bill limits and clarifies the FDA's role regarding regulation of administrative and financial software, wellness and lifestyle products, certain aspects of electronic health records and software that aids health care providers in developing treatment recommendations for their patients.

Bipartisan Legislation Introduced in Senate to Make Bids Binding in Medicare DME Auctions

Senators Ben Cardin (D-MD) and Rob Portman (R-OH) introduced a bill Dec. 4 that would make bids binding in Medicare's durable medical equipment (DME) auctions. The bill, which tries to prevent low-ball bids, an inherent result in bidding programs that do not require companies to honor their bids, aims to create a more fair and transparent competitive bidding program for Centers for Medicare & Medicaid Services (CMS) contracts and expand access to affordable medical supplies for seniors, all while providing a fair playing field for the small businesses that supply DME for the contracts. Currently, critics of CMS' existing DME bidding program say that companies submit low-ball bids if there is a chance the winning bid will be higher than theirs, as the agency chooses the median price among the bidders selected for contracts; if too many suppliers submit low-ball bids, the median bid ends up being below the naturally competitively bid level. In a press release from Cardin and Portman the senators said, "The Medicare Competitive Bidding Improvement Act would make supplier bids binding, thereby increasing transparency and ensuring reliable and equitable pricing. This legislation would help ensure that suppliers submit bids in good faith, increase competition, and would create more certainty for suppliers and for consumers, giving them increased access to more quality products and services."

2. ADMINISTRATION

HHS Releases Report Showing 17 Percent Reductions in Hospital-Acquired Conditions

The Department of Health and Human Services (HHS) released a preliminary report Dec. 2 detailing estimates that show a decrease of 1.3 million hospital-acquired conditions among patients from 2010 to 2013, a 17 percent decline over the three-year period. The Administration also found that national efforts to improve patient safety prevented as many as 50,000 patient deaths in hospitals and saved approximately $12 billion in health care costs during the same time period. "Today's results are welcome news for patients and their families," said HHS Secretary Sylvia M. Burwell. "These data represent significant progress in improving the quality of care that patients receive while spending our health care dollars more wisely. HHS will work with partners across the country to continue to build on this progress." Specifically, HHS found that adverse drug events fell 19 percent from 2010 to 2013; catheter-associated urinary tract infections dropped by 28 percent; central line associated bloodstream infections declined by 49 percent; pressure ulcers dropped by 20 percent; and surgical site infections fell by 19 percent over the period. Although HHS noted that the precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse events, spurred in part by Medicare payment incentives and catalyzed by the U.S. Department of Health and Human Services (HHS) Partnership for Patients initiative led by the Centers for Medicare & Medicaid Services (CMS).

HHS Fall 2014 Agenda Released; Contains Details of Rules in Various Stages of Agency Development

On Nov. 21, the White House Office of Management and Budget (OMB) released its Fall 2014 Agenda for the Department of Health and Human Services (HHS), which included several Medicare rules, including those that are updated annually. One of the many rules listed included a final rule to implement "the remaining policies not finalized" for 2015 under the Medicare Advantage (MA) and Part D prescription drug benefit programs, which contained a variety of controversial changes to the MA and Part D programs, including those on criteria for protected drug classes, preferred pharmacies, noninterference and the medication therapy management programs. Another noteworthy proposed regulation listed on the agenda concerns updating regulations for managed care under the Programs of All-Inclusive Care for the Elderly (last published in 2006) and proposed special payment rules for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), which has a planned publication date for a proposed rule in May 2015. Other Medicare rules mentioned are those updated annually, including calendar year 2016 Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Medicare Part B and 2016 Part B Monthly Actuarial Rates, Monthly Premium Rates, and Annual Deductible.

President Signs Medicare Bill into Law; Enacts Enforcement Delay on Supervision Requirements for Outpatient Therapy at Critical Access and Rural Hospitals

On Dec. 4, President Barack Obama signed H.R. 4067 (the Protecting Access to Rural Therapy Services [PARTS] Act), effectively delaying Medicare's enforcement of unreasonable and inflexible direct supervision rules for outpatient therapy services at Critical Access Hospitals (CAHs) and other small, rural hospitals in 2014. The legislation, authored by Rep. Lynn Jenkins (R-KS) and Sen. Jerry Moran (R-KS), passed the Senate in November and the House of Representatives in September 2014. "Imposing an unrealistic and clinically unnecessary supervision policy jeopardizes patients' access to important services in communities in Kansas and across the country," Sen. Moran said. "This one-year delay is needed because many Kansas hospitals are considering cutting services." The members hope to make the legislation permanent for years after 2014 in the next Congress.

CMS Final Rules Aimed at Fighting Fraud Through Increased Provider Oversight

On Dec. 3, CMS Administrator Marilyn Tavenner announced new rules that strengthen oversight of Medicare providers by preventing physicians and other providers with unpaid debt from re-entering Medicare, removing providers with patterns or practices of abusive billing, and implementing other provisions estimated to save more than $327 million annually. Specifically, the new rules will allow CMS to deny enrollment to providers, suppliers and owners affiliated with any entity that has unpaid Medicare debt. In addition, the final rules will allow CMS to deny or revoke the enrollment of a provider or supplier if a managing employee has been convicted of a felony offense that CMS determines to be detrimental to Medicare beneficiaries, or if the provider is engaging in abuse of billing privileges by demonstrating a pattern or practice of billing for services that do not meet Medicare requirements. CMS will continue its current enrollment moratoria on new ambulance and home health providers in select high-fraud areas, which allows the agency to target its resources, including use of fingerprint-based criminal background checks.

CMS Final Rule -- Medicaid Program; Disproportionate Share Hospital Payments -- Uninsured Definition

On Nov. 28, CMS released a final rule to address the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments under the Social Security Act (the Act). Under this limitation, DSH payments to a hospital cannot exceed the uncompensated costs of furnishing hospital services by the hospital to individuals who are Medicaid-eligible or "have no health insurance (or other source of third party coverage) for the services furnished during the year." This rule provides that, in auditing DSH payments, the quoted test will be applied on a service-specific basis, so that the calculation of uncompensated care for purposes of the hospital-specific DSH limit will include the cost of each service furnished to an individual by that hospital for which the individual had no health insurance or other source of third-party coverage. The final rule is effective Dec. 31, 2014.

3. STATE ACTIVITIES

Pennsylvania Governor Names Medicaid Adviser for Transition; Hopes to Implement Full Expansion

On Nov. 21, Pennsylvania's Gov.-elect Tom Wolf, a Democrat, announced that Estelle Richman, former Public Welfare Secretary under former Democratic Gov. Ed Rendell, would advise him on Medicaid, thereby indicating his intentions to undo previous efforts toward the conservative-friendly Medicaid expansion waiver led by Republican Gov. Tom Corbett. The waiver, part of an effort called Healthy PA, was recently approved by Centers for Medicaid & Medicare Services (CMS). Healthy PA reforms Medicaid for existing users and provides private-option coverage for 600,000 previously uninsured. Enrollment for Corbett's plan began on Dec. 1, with plans taking effect on Jan. 1. The effort also included separate low- and high-risk plans that offer different kinds of coverage based on health condition and was designed to cover the working poor, applying to those with incomes up to 133 percent of the federal poverty level, or $15,500 for an individual in 2014. "Ensuring that all Pennsylvanians have access to quality, affordable health care is one of my top priorities, and we can achieve this by fully expanding Medicaid. Secretary Richman's experience and expertise will be crucial to moving toward full Medicaid expansion, which is both the right thing to do for thousands of Pennsylvanians and their families and the right thing to do for the economy," said Gov.-elect Wolf in a statement. Richman is an experienced public servant, having served as the COO of the Department of Housing and Urban Development (HUD) under President Obama, Managing Director for the City of Philadelphia, Director of Social Services for the City of Philadelphia and Philadelphia Commissioner of Public Health.

New Mexico Looking to Adopt Market-Wide Assessment on Certain Insurance Carrier Premiums to Raise Funds for State Exchange Operations

In a board meeting for the New Mexico Health Insurance Exchange (NMHIX) on Nov. 21, regulators released materials showing their intention to adopt a market-wide assessment on certain insurance premiums in order to raise the necessary funding for the exchange to sustain itself operationally in the future. In the program, which is outlined in proposed amendments to Article XIII Financial Stability, insurance carriers that would have to pay the fee are ones offering major medical coverage on or off the exchange, or sell any product on the exchange, such as dental plans. As it stands, New Mexico has to sustain its own SHOP exchange starting in 2015, and the state believes $1.5 million will be needed to fund its operation. Also worth noting, the state exchange has to figure out individual exchange funding by 2016. The board is encouraging public comment on the proposed amendments, with stakeholder feedback due by Dec. 19, 2014.

A fact sheet on the amendments and the public comment process, which was posted Nov. 26, can be found here.

Illinois House Withholds Vote on State-Based Health Insurance Exchange

On Dec. 3, the Illinois General Assembly decided not to vote on a measure that would fund the development of a state health insurance exchange marketplace, effectively killing the measure until a new legislative session in 2015. The bill, sponsored by Rep. Robyn Gabel, D-Evanston, would have guaranteed future funding for the exchange by taxing insurers. Democratic House Speaker Michael Madigan really pushed for bipartisan support on the measure because the exchange system would require a new government agency to run it; however, Republicans largely opposed the legislation, noting that new Republican Gov.-elect Bill Rauner asked them to wait on substantive issues until he was sworn into office in January. This is the last year the federal government is offering financial assistance to states to set up their own exchanges. Fourteen states and the District of Columbia launched their own exchanges last year with federal grants, and approximately $270 million in federal funding was left on the table when lawmakers decided to forfeit the vote. Approving a state-based exchange would also have protected Illinois subsidies from a pending Supreme Court decision that would have taken exchange subsidies away from low-income individuals who purchased insurance in states operating through a federally based insurance exchange.

4. REGULATIONS OPEN FOR COMMENT

CMS Releases Proposed Rule on ACA Benefit and Payment Parameters for 2016

In a Nov. 21 press release, the Centers for Medicare & Medicaid Services (CMS) announced the issuance of a proposed rule (CMS-9944-P) covering a wide range of Affordable Care Act policies for individual and small group health plans, both inside and outside the ACA marketplaces, including payment parameters and provisions related to the risk adjustment, reinsurance and risk corridors programs; cost-sharing parameters and cost-sharing reductions; and user fees for federally facilitated exchanges. The rule, entitled "HHS Notice of Benefit and Payment Parameters for 2016," would provide additional standards for the annual open enrollment period for the individual market for benefit years beginning on or after Jan. 1, 2016, and has provisions affecting essential health benefits, qualified health plans, network adequacy, quality improvement strategies, the Small Business Health Options Program, guaranteed availability, guaranteed renewability, minimum essential coverage, the rate review program and the medical loss ratio program. The rule was published in the Federal Register Nov. 26 and stakeholder comments are due Dec. 26.

CMS Releases Memo Seeking Comments on Changes to Ratings for Medicare Advantage, Drug Plans in 2016

In a memorandum released Nov. 21 by the Centers for Medicare & Medicaid Services (CMS), the agency is seeking comments on possible changes to its star rating system for Medicare Advantage (Part C) and prescription drug plans (Part D). The ratings, which grade plans on a scale of one to five and affect payments to Medicare Advantage plans, and other changes would be implemented for the 2016 contract year and will be further discussed in CMS' Call Letter in February 2015. Among the possible adjustments that CMS is investigating are the potential development of an integrated star rating system for Medicare-Medicaid Plans (MMPs) participating in the agency's capitated financial alignment demonstration for dually eligible beneficiaries. The memo said that a rating system for the managed care plans involved in some of the demos would acknowledge "the additional needs of Medicare-Medicaid enrollees and measure the performance of the MMPs in integrating the Medicare and Medicaid benefits." CMS also said it would be analyzing 67 responses received in September, when the agency posted a request for information (RFI) asking the public whether these plans have more problems than others with the quality ratings and further sought experiences or research into whether high-quality performance could be achieved, regardless of the enrollment level of low-income beneficiaries. Among the other possible changes outlined in the memo, the agency said for the 2016 ratings, it plans to remove its "pre-determined measure thresholds," which have been used since 2011 for certain measures partly to "set expectations for high performance." Furthermore, CMS said to help beneficiaries make more informed choices and to be as transparent as possible about the performance of all plans, it is moving toward including low-enrollment contracts in the star ratings beginning with the 2016 star ratings. Comments on the ratings alterations are due by Dec. 17.

CMS Releases Proposed Rule Aimed to Strengthen ACOs

In a Dec. 1 press release, the Centers for Medicare & Medicaid Services (CMS) announced a new proposed rule looking to improve the Shared Savings Program (SSP) for Accountable Care Organizations (ACOs) through a greater emphasis on primary care services and promoting transitions to performance-based risk arrangements. Through the Affordable Care Act (ACA), ACOs encourage doctors, hospitals and other health care providers to work together to better coordinate care when people are sick and keep people healthy, which helps to reduce growth in health care costs and improve outcomes. CMS Administrator Marilyn Tavenner said, "This proposed rule is part of our continued commitment to rewarding value and care coordination -- rather than volume and care duplication. We look forward to partnering with providers and stakeholders to continuously refine and improve the Medicare Shared Savings program." Other goals of the rule include providing more flexibility for ACOs seeking to renew their participation in the program, encouraging ACOs to take on greater performance-based risk and reward, creating alternative methodologies for benchmarks, and streamlining data sharing and reducing administrative burden. The SSSP now includes more than 330 ACOs in 47 states, providing care to more than 4.9 million beneficiaries in Medicare fee for service. Recently, CMS announced first-year SSP results, finding that 58 SSP ACOs held spending below their benchmarks by a total of $705 million and earned shared savings payments of more than $315 million, and that another 60 ACOs had expenditures below their benchmark, but not by a sufficient amount to earn shared savings. Comments on the proposed rule are due by Feb. 6. A fact sheet accompanying the proposed rule can be found here.

OPM Proposes New Multi-State Plan Rule

The U.S. Office of Personnel Management (OPM) is issuing a proposed rule to implement modifications to the Multi-State Plan (MSP) Program based on the experience of the Program to date. OPM established the MSP Program pursuant to Section 1334 of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. This proposed rule clarifies the approach used to enforce the applicable requirements of the Affordable Care Act with respect to health insurance issuers that contract with OPM to offer MSP options. This proposed rule amends MSP standards related to coverage area, benefits and certain contracting provisions under Section 1334 of the Affordable Care Act. This document also makes non-substantive technical changes. Comments are due on or before Dec. 24, 2014.

CMS Releases Proposed Rule on Revised Conditions of Participation for Home Health Agencies

The Centers for Medicare & Medicaid Services (CMS) released a proposed rule on Oct. 6 revising and modernizing the current conditions of participation for home health care agencies that want to take part in the Medicare and Medicaid programs. The CMS rule, published in the Federal Register on Oct. 7, "reflects the most current home health agency practices by focusing on the care provided to patients and the impact of that care on patient outcomes. This proposed regulation focuses on assuring the protection and promotion of patient rights; enhances the process for care planning, delivery, and coordination of services; streamlines regulatory requirements; and builds a foundation for ongoing, data-driven, agency-wide quality improvement." Specific new provisions in the proposed rule include patients' rights measures, coordination of services and quality of care measures utilizing an interdisciplinary team approach, quality assessment and performance improvement (QAPI) measures, and infection prevention and control measures, among others. Comments on the proposed rule are due to CMS by Dec. 8, 2014.

CMS Releases Final Rule for Medicare Program: Physician Fee Schedule OPPS, ASC Payments, End-Stage Renal Disease

On Oct. 31, the Centers for Medicare and Medicaid Services (CMS) released its final rule for CY 2015 Medicare reimbursement payments to physicians and non-physician practitioners, hospital outpatient departments (OPPS), ambulatory surgical centers (ASCs), and home health agencies and dialysis facilities that treat patients with end-stage renal disease. Specifically, the CY 2015 OPPS/ASC final rule with comment period updates Medicare payment policies and rates for hospital outpatient department and ASC services and partial hospitalization services provided by community mental health centers (CMHCs), and refines programs that encourage high-quality care in these outpatient settings. In CY 2015, CMS is implementing a policy finalized last year regarding comprehensive Ambulatory Payment Classifications (C-APCs), with some refinements and updates.

OPPS

Overall OPPS payments are expected to increase by 2.3 percent for CY 2015. Also noteworthy in the rule, CMS has finalized a proposal to package prosthetic supplies as it does implantable prosthetic devices, and all other supplies in the OPPS when used in conjunction with a surgical or other procedure. Other significant OPPS payment modifications addressed in the statute include reimbursements for skin substitutes, off-campus provider-based departments, hospital outpatient outlier payments, community mental health center outlier payments, ancillary services and Part B drugs in the outpatient department.

ASC Payment Updates

For CY 2015, ASC payments will increase by 1.4 percent, accounting for the MFP-adjusted CPI-U update factor, which accounts for inflation.

Partial Hospitalization Program (PHP) Rates

CMS will update the two payment rates for CMHCs and the two payment rates for hospital-based PHPs. For community health centers the final CY 2015 APC geometric mean per diem cost will be $100.15 for Level I (three services) and $118.54 for Level II (four or more services). For hospital-based PHPs, the final CY 2015 APC geometric mean per diem cost will be $185.87 for Level I and $203.01 for Level II.

End-Stage Renal Disease

The finalized provisions in End-Stage Renal Disease (ESRD) Prospective Payment System rule introduce new quality and performance measures for outpatient dialysis facilities; moreover, the rule incorporates in 2017 a Standardized Readmission Ratio, which assesses the rate at which ESRD dialysis patients return to an acute care hospital within 30 days of discharge from an acute care hospital.

Other Policy Changes

CMS has finalized an internal process, to be used in limited circumstances, that will allow CMS to recover overpayments from erroneous payments made by Medicare Advantage (MA) organizations or Part D prescription drug plan sponsors; CMS has also finalized an appeals process for MA organizations and Part D sponsors to seek review of CMS' determination that the payment data are erroneous. The appeals process will have three levels of review that would include reconsideration, an informal hearing and an Administrator review.

CMS also finalized a proposal that requires the physician certification only for outlier cases and long-stay cases of 20 days or more. A hospital admission order will continue to be required for all inpatient admissions when a patient has been formally admitted as an inpatient of the hospital.

The final rule is slated to be published in the Federal Register on Nov. 6. The provisions in the rule will generally take effect on Jan. 1, 2015, and the public comment period will close on Dec. 30, 2014.

More information on the rule can be found in a CMS factsheet that accompanies the rule's release.

5. REPORTS

Medicare Program Integrity: CMS Pursues Many Practices to Address Prescription Drug Fraud, Waste and Abuse

As part of a report released Nov. 24, GAO identified 23 practices for addressing prescription drug fraud, waste and abuse that fall within three categories based on GAO's Fraud Prevention Framework -- prevention, detection and monitoring, and investigation and prosecution. GAO found that HHS' Centers for Medicare & Medicaid Services (CMS) activities to address prescription drug fraud, waste and abuse in the Medicare Part D prescription drug program reflect 14 of these 23 identified practices, some of which are in multiple categories, and the agency plans to implement three additional practices. To develop a list of practices for addressing prescription drug fraud, waste and abuse, GAO interviewed 14 stakeholder groups involved in various aspects of prescription drug program integrity, including provider, beneficiary and anti-fraud groups; identified and reviewed related documents; and conducted a search of eight bibliographic databases that included peer-reviewed articles and government documents. GAO organized the practices based on the three categories of GAO's Fraud Prevention Framework. To determine how CMS oversight reflects these practices, GAO analyzed agency documents, such as contracts, manuals, work products and CMS audits of contractors; and interviewed agency officials. HHS generally agreed with GAO's findings.

Private Health Insurance: Concentration of Enrollees Among Individual, Small Group and Large Group Insurers From 2010 Through 2013

According to a report released Dec. 1 by GAO, while several insurers participated in each state's individual, small group and large group health insurance markets in 2013, enrollment was concentrated among the three largest insurers in most states. In each of the three market segments, the three largest insurers had at least 80 percent of the total enrollment in at least 37 states. In more than half of these states, a single insurer had more than half of the total enrollees and in five of these states there was at least one market segment in which the largest insurer had at least 90 percent of all the enrollees. In the remaining states -- 12 states' individual markets, 14 states' small group markets and 11 states' large group markets -- more insurers participated and the market segments were less concentrated, with enrollment spread out among more insurers. GAO produced the report as part of its obligation under the ACA to study competition and market concentration in the health insurance market. For this study, GAO examined individual, small group and large group health insurance markets prior to the implementation of key PPACA provisions that went into effect in 2014 and that could affect competition and market concentration among health insurers.

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