December 6, 2013 -- The accuracy of the enrollment files that are sent daily from the healthcare.gov website to insurance companies is improving from an error rate of about one in four from Oct. 1 through Nov. 30 to a current rate of about one in 10, according to Obama administration officials.

The administration says it is working with insurance companies to identify remaining flaws. The "very preliminary" information released late last week is based on a sample of files that federal officials and insurers compared.

The problems with the so-called 834 enrollment forms fall into three categories, said Centers for Medicare & Medicaid Services (CMS) Communications Director Julie Bataille. They include enrollment information that is never sent to insurers, duplicate forms, and forms that included errors. Bataille said officials "don't have breakdowns" of the number of problems in each category.

Insurance companies are most concerned about the missing forms, which they have dubbed "ghost" or "orphan" reports. They are concerned that consumers may believe they have coverage when insurers, in fact, have no record of enrollment.

Insurers working with CMS said they are pleased that the errors are not as common as they once were, but note problems could be magnified as the volume of enrollment increases.

"The new process put in place this week is making a difference," said America's Health Insurance Plans President and CEO Karen Ignagni. "The enrollment files are getting better, but there is more work to do to ensure consumers are covered."

Traffic on the federal website continued to grow this week. About 3.7 million unique visitors through noon on Friday clicked on healthcare.gov, which handles enrollment in the health law insurance exchanges for 36 states. The site was unusually stable this week, with no unscheduled crashes, an error rate of 0.77 percent and response times of less than 1 second.

The administration used its new queuing system, which asks consumers to get off the site and return later, on Monday morning and Tuesday afternoon. But Bataille said 93 percent of the 16,000 people who left the site returned after they got an email telling them that healthcare.gov was running more smoothly and they could try again.

People have until Dec. 23 to sign up and until Dec. 31 to pay their premiums. Coverage is supposed to start on Jan. 1.

Insurance industry consultant Bob Laszewski said that insurers are worried about the tight time frame. He said that one of his clients estimated that only about 15 percent of people who enrolled have paid. It's impossible to predict how many will pay by Dec. 31.

"We should expect some enrollment slippage come the payment due date," he said.

If a customer doesn't pay by Dec. 31 but pays a few days later, the individual will have to wait until Feb. 1 to get coverage.

By John Reichard, CQ HealthBeat Editor

December 6, 2013 -- The Centers for Medicare and Medicaid Services (CMS) is extending through 2016 so-called "stage two" requirements for the "meaningful use" of health information technology, a term that determines whether a providers qualifies for Medicare and Medicaid bonus payments.

The meaningful use program has three stages of requirements: the first to begin reporting data to improve the efficiency and quality of care; the second to promote the exchange of that data with other providers and with consumers; and the third to beef up the amount of stage two data that is generated.

Hospitals in particular have complained that the stage two requirements are starting too soon.

The timeline varies for individual providers, depending on when each hospital or physicians' office enrolled in the program.

Health care providers who started the meaningful use process in the early stages, in 2011 or 2012, will have one extra year to demonstrate the Stage 2 requirements. Instead of starting the third stage of the process in 2016, they will have until 2017.

The revised timeline also says that stage three will start in 2017 for providers that have completed at least two years in stage two. The goal of the changes is to allow CMS and the Office of the National Coordinator for health information technology at the U.S. Department of Health and Human Services (HHS) to "focus efforts on the successful implementation of the enhanced patient engagement, interoperability, and health information exchange requirements in stage two," HHS said in a document titled "eHealth Blog."

A second goal is to "utilize data from Stage Two participation to inform policy decisions in Stage Three."

HHS also is pursuing a new approach to certification of health information technology. It's designed in part to "enable our certification processes to more quickly adapt to include newer industry standard," and to "add more predictability for electronic health record technology developers," an HHS official said.

By Rebecca Adams, CQ HealthBeat Associate Editor

December 6, 2013 -- Pennsylvanians will get a chance to weigh in on Republican Gov. Tom Corbett's Medicaid expansion plan in six hearings and two webinars before the state formally sends its plan, which contains controversial work requirements for beneficiaries, to federal officials for approval.

Corbett released his 97-page draft waiver request Friday morning. The last event is scheduled for Jan. 9. State officials say they don't know how long it will take to polish the proposal after the hearings.

State officials say they have coordinated closely with federal officials on the governor's "Healthy Pennsylvania" plan.

But some parts of it cause concern for consumer advocates. Those include the imposition of monthly premiums as well as requirements that non-disabled people who are working less than 20 hours per week look for more work. Pennsylvania would be the first state to require people to participate in a job search or training program to get Medicaid benefits.

Under Corbett's Medicaid plan, people who are between the ages of 21 and 65 who are working less than 20 hours weekly would have to register with the state's online system for residents who are registered with the unemployment insurance program. Those people would have to do 12 "work search" activities per month during the first six months of coverage in order to keep their Medicaid coverage.

A spokeswoman said those activities could include attending a job fair, looking for jobs posted on the state online system, creating or posting a resume online or contacting people to let them know of the applicant's job search. The activities also could include using a job search service, taking a civil service test or other pre-employment test, or applying for a job.

The premium for new enrollees would be set up on a sliding scale based on income, and recipients could get lower rates for meeting certain requirements like an annual physical, completing a health assessment and paying premiums on time.

By Emily Ethridge, CQ Roll Call

December 6, 2013 -- The Congressional Budget Office (CBO) in a one-page memo on last week once again lowered the cost for repealing Medicare's physician payment formula, saying a 10-year repeal would cost about $23 billion less than an earlier estimate this year found.

That even-lower cost is sure to add momentum to lawmakers' efforts to repeal the formula and replace it with different payment system. According to the CBO, the cost of repealing the sustainable growth rate formula would now be $116.5 billion over 10 years — less than half of what the CBO estimated it would cost to do in 2012.

Physician groups had already been urging lawmakers to seize the opportunity to get rid of the SGR while the cost of repeal was low. An estimate earlier this year put the cost of repealing the SGR at $139.1 billion over 10 years. The most recent CBO estimate is sure to bring more hope to stakeholders that a permanent replacement can be achieved.

The Senate Finance Committee plans to mark up a replacement proposal it crafted with the House Ways and Means Committee, which may also hold its own markup next week.

The new estimate did not provide an explanation for the lowered costs.

Along with adding energy to the overall replacement effort, the estimate could also help a measure (HR 2810) approved in July by the House Energy and Commerce Committee. The CBO said that bill would cost $153.2 billion over 10 years, down from its previous estimate of $175.5 billion.

One of the biggest obstacles to passing a permanent SGR replacement has been figuring out a way to offset the cost of doing so. Lawmakers insist that any measure be fully offset, but so far have not publicly discussed possible ways to pay for it.

With time running short this year, physician groups have asked lawmakers to pass a short-term payment patch to stave off rate cuts that will occur Jan. 1, while still working on their replacement bills.

The CBO estimate notes that the Center for Medicare and Medicaid Services recently issued a final rule saying the cuts to physicians next year would be 20.1 percent. But other adjustments included in the rule will mean physician payments will effectively be cut by 23.7 percent if Congress doesn't act, the office said.

The cost of a yearlong "doc fix" that freezes provider payments for one year would be $19.6 billion over 10 years, the CBO said. Giving providers a 0.5 percent increase for 2014 would cost $18.7 billion over 10 years, the memo said. It was not clear why an increase would cost less over 10 years than a payment freeze.

American Medical Association President Ardis Hoven urged lawmakers to make the payment patch shorter than one year.

"To get a landmark bill to the finish line early next year, the AMA supports a very short term 'bridge' to stop the looming 2014 Medicare payment cut for just a couple months," Hoven said in a statement. "We cannot afford any proposal that maintains the status quo for another year on a policy that is a proven failure."

By Emily Ethridge, CQ Roll Call

December 5, 2013 -- Lawmakers on House and Senate committees have made a number of changes to their joint, bipartisan proposal to replace how Medicare pays physicians, in hopes of having dual markups on the legislation next week.

The alterations to the draft legislative framework reflect comments from provider and patient groups, as well as other stakeholders. The Senate Finance Committee is slated to mark up the proposal Dec. 12, and the House Ways and Means Committee may also hold its own markup next week.

"The Committee has made real progress on a bipartisan and bicameral bill," said House Ways and Means Committee Chairman Dave Camp, R-Mich., in a statement. "If that progress continues, I expect the Committee to consider the legislation before the end of next week."

Stakeholders say they are mostly pleased with the changes. But with time running short before the end of the year, lawmakers are also looking at passing a short-term payment patch, most likely for three months, to buy more time for the replacement bill.

If Congress doesn't act, physicians will see their Medicare reimbursement rates cut by about 24 percent after Dec. 31. House Majority Leader Eric Cantor, R-Va., said last week it was possible that legislation related to Medicare physician payments could be on the House floor next week, though he was not specific about what it might be. The House is scheduled to be in recess after Dec. 13.

Rep. Michael C. Burgess, R-Texas, said the scheduling of the Senate Finance markup so close to recess "sort of guarantees" that lawmakers must to do something in the short term to avoid the cuts.

"I don't like it, but I don't want to see doctors have their rates slashed or their checks held," he said. "The bottom line is that we've got to protect the people that are taking care of our seniors."

But several stakeholders warned that the patch should not be too long, so as not to lose momentum behind the replacement.

Burgess said he would push to bring a replacement bill to the House floor within that three-month patch period. "I've had some encouragement about that, not at lot, but I have had some encouragement that that is possible," he said.

He also noted that the GOP Doctors Caucus, of which he is a member, is working on a payment proposal that would incorporate elements of the different committee bills, including his bill (HR 2810) that the Energy and Commerce Committee approved in July.

"Obviously my personal bias is it should hew very closely to the Energy and Commerce product," he said.

As for the dual committee proposal, aides to the Senate Finance Committee and House Ways and Means Committee briefed provider groups on the updates to the draft measure on Wednesday night. The framework would repeal Medicare's current payment formula, and allow physicians to either stay in Medicare's traditional fee-for-service system or move to alternative payment models.

Physicians who remain in the fee-for-service program would have their payment rates frozen for 10 years, but would be able to receive bonus payments through a new, combined, value-based purchasing program.

One of the changes made to the draft framework addresses a physician group concern that that program would force providers to compete against each other to get those bonus payments, rather than sharing best practices.

Under the revised version, instead of simply being rated on whether they achieved certain scores, physicians will also get credit for improving from one year to the next in quality and use of resources.

The updated framework also gives physicians more time to adjust to the value-based purchasing program, and ties less payment to performance for the initial years than under current law. It also allows nurse practitioners, physician assistants, clinical nurse specialists and certified registered nurse anesthetists to participate in the program starting in 2017, up from 2018.

The new framework would make all small practices of 10 or fewer physicians eligible for additional funding to help them move to alternative payment models or the value-based purchasing program. Previously, the funding was available only for practices in rural areas or in areas with a physician shortage. Those groups would still be prioritized under the updated version.

The lawmakers removed a 10 percent penalty on physicians who do not report data to a project to find misvalued Medicare codes, but kept the incentive payments for reporting.

For the alterative payment models, the updated draft would provide a "cushion" for physicians who want to participate in new models but do not quite reach the required amount of revenue received from Medicare patients each year.

The new "partial qualifying APM participant" category would apply to physicians who come close to qualifying for that year's revenue threshold. Those providers could choose to instead participate in the value-based purchasing program and get a bonus, or choose not to and receive no payment adjustment.

By Rebecca Adams, CQ HealthBeat Associate Editor

December 2, 2013 -- Federal Medicaid officials will allow states to enroll people without receiving the actual applications they complete through healthcare.gov.

The move is a tacit acknowledgement that in most cases the transfer of application information between the federal insurance exchange and the 36 states it serves will not be ready right away.

The workaround also will apply to enrollment in the Children's Health Insurance Program. "This process will ensure that coverage will begin on Jan. 1 for newly eligible enrollees," said Centers for Medicare and Medicaid Services spokeswoman Emma Sandoe.

States can obtain waivers from the federal government to enroll people in Medicaid using the workaround, Centers for Medicare and Medicaid Services (CMS) Deputy Administrator Cindy Mann said in a four-page letter to state officials that was posted online Nov. 30.

"It's indicative of how much work really is needed on all sides to get from where we are to where we need to be," said Matt Salo, executive director of the National Association of Medicaid Directors.

Healthcare.gov is supposed to send complete application information electronically but federal officials have not completed a fix to make that happen.

However, they are eager to get people enrolled as quickly as possible. In most of the states that are expanding Medicaid under the health care law, benefits can start on Jan. 1. The law (PL 111-148, PL 111-152) allows states to expand Medicaid to people with income of up to 138 percent of the federal poverty level.

CMS has delayed the start of electronic transfer several times. The function, known as "account transfer," was initially supposed to begin when the federal website went live on Oct. 1.

But CMS officials notified states before the launch that those transfers would have to wait until Nov. 1 because the function was not ready. Then in a Nov. 1 phone call, Mann told officials she hoped testing of the system could start in coming weeks. State officials predicted the site would be able to transmit Medicaid application data back and forth in late November with some states. Testing of that process has now started in a few states.

In the meantime, federal officials have been sending basic demographic data in so-called "flat files." That information isn't as complete as the data in the applications. However, it provides state officials with names and other details so that they can contact applicants if needed, and estimate the number of applicants who appear to be eligible for Medicaid.

In the letter, Mann said the basic data would be expanded so that state officials will have enough details to be able to enroll applicants.

The expanded file will include an applicants' date of birth and Social Security number, and the category under which the applicant seems to qualify for Medicaid. Individuals could be eligible for Medicaid under a range of previously existing criteria, or under an expanded category for adults that is allowed under the health care law.

"The file will also identify the individuals that cannot be enrolled through this process because they have an income or residency verification inconsistency, or because they have been referred" on a basis that uses outdated income criteria, Mann said. Under the law, states are supposed to determine eligibility by using "Modified Adjusted Gross Income," a formula that states did not use until now.

Salo said he had not been told when the additional details would be provided, or when the files will be checked more closely to catch errors such as missing fields of information or incorrect data.

"The flat files have not to date provided enough information to enroll people," he said. "If I had to pick a day, I'd say tomorrow, but I don't know" for sure when the changes will be made.

The workaround requires more labor on the part of state employees. They will have to manually enter the information or spend money to try to develop an electronic conversion tool.

"Who's going to take that option—and how well will it work?" Salo asked.

CMS also advised state officials what they should do if they determine that someone does not qualify for Medicaid who at first appeared to be eligible.

The state would provide "appropriate advance notice" to the enrollee, wrote Mann. "Individuals would have an opportunity to appeal the determination to terminate coverage," she added. "States would have the option, but would not be required, to provide benefits pending the outcome of a fair hearing."

But Salo said CMS has not addressed details states would like to know. For example, if a state inappropriately enrolls or denies someone coverage, would the state be penalized?

"How are states going to be held accountable for making decisions in an imperfect environment?" asked Salo. "If someone is covered for three or six months, do we have to pay CMS back for that?"

A CMS spokeswoman said that states will not be at risk of losing federal funding if state officials follow the procedures that are provided in the letter to enroll people that the federal marketplace has said appear to qualify for Medicaid.

States will have authority to use the expanded flat file data to enroll people for up to 90 days. They may be able to extend coverage for an additional period based on state circumstances. When the full account transfer function is working at healthcare.gov, states would be required to use that method instead of the temporary fix, wrote Mann.