RISE looks at the latest headlines that impact Medicare and Medicaid.
Feds charge hundreds in $6B health care fraud case, the largest ‘takedown’ in history
The Department of Justice on Wednesday announced it had charged 345 defendants across 51 federal districts with submitting more than $6 billion in false and fraudulent claims to federal health care programs and private insurers. The fraud involves more than $4.5 billion connected to telemedicine, more than $845 million connected to substance abuse treatment facilities, and more than $806 million connected to other health care fraud and illegal opioid distribution across the country.
Among those charged: more than 100 doctors, nurses, and other licensed medical professionals. It is the largest health care fraud and opioid enforcement action in the Justice Department’s history. In addition, the CMS Center for Program Integrity separately announced it revoked the Medicare billing privileges of 256 additional medical professionals for their involvement in telemedicine schemes.
“This nationwide enforcement operation is historic in both its size and scope, alleging billions of dollars in health care fraud across the country,” Acting Assistant Attorney General Brian C. Rabbit said in the announcement. “These cases hold accountable those medical professionals and others who have exploited health care benefit programs and patients for personal gain. The cooperative law enforcement actions announced today send a clear deterrent message and should leave no doubt about the department’s ongoing commitment to ensuring the safety of patients and the integrity of health care benefit programs, even amid a national health emergency.”
More consumers on ACA exchanges chose plans with lower premiums, higher out-of-pocket costs
A new analysis from the Robert Wood Johnson Foundation and Urban Institute finds that “silver loading” on the Affordable Care Act’s insurance exchanges caused more consumers to enroll in bronze tier plans with lower premiums but higher out-of-pocket costs. The report notes that the practice of silver loading began when the U.S. Department of Health and Human Services stopped directly reimbursing insurers for cost-sharing reductions provided to the marketplace enrollees with the lowest incomes. But insurers still had to offer cost-sharing-reduction plans to eligible consumers and incorporate the cost into premiums they charged for nongroup market plans. Many states instructed insurers to add the expected cost of the subsidies to the premiums for their silver plans, an approach known as silver loading.
Key findings from the report noted that in 2017, on average, a benchmark (second lowest priced) silver premium was 21 percent higher than the lowest-priced bronze plan available to consumers. In 2018, after federal reimbursement of cost-sharing subsidies ended, the silver plan premiums rose to an average of 38 percent above the lowest-premium bronze plan, sparking an 11-percentage-point drop in the share of marketplace enrollees buying silver plans. Most of that enrollment drop shifted into lower priced bronze plans, coverage that requires substantially higher out-of-pocket costs when using medical care.
“This approach increased silver premiums relative to other levels of coverage, increasing the federal cost of providing premium subsidies and making silver plans more expensive relative to other tiers of insurance offered,” the analysis concluded. “Because the Trump Administration also dramatically decreased funding for enrollment navigators, many consumers may be unaware that switching to a bronze plan not only lowers their monthly premium, but also increases their risk of high out-of-pocket expenses.”
CMS releases first monthly Medicaid and CHIP enrollment trends snapshot
The Centers for Medicare & Medicaid Services (CMS) this week released a summary report that shows Medicaid and CHIP program enrollment trends for adults and children over a 12-month period. The snapshot shows more than 4 million new Medicaid and CHIP enrollments between February and June 2020, a 5.7 percent increase since the COVID-19 public health emergency. CMS said it would release a snapshot on enrollment trends every month and is available here.
The rate of uninsured in America was up even before COVID-19
Roughly 5.4 million American adults lost their health insurance due to job losses from February to May due to COVID-19. But a new study from the Centers for Disease Control and Prevention finds that nearly 2.5 million more working-age Americans were uninsured in 2019 prior to COVID-19 The report found that in 2019, 14.5 percent of adults aged 18-64 were uninsured in the United States. The most common reason for lacking insurance: the coverage was not affordable. The percentage of uninsured adults who were uninsured because of unaffordable coverage increased with age, from nearly 67 percent among those aged 18-29 to nearly 81 percent among those aged 50-64. Hispanic adults were more likely than non-Hispanic white adults to indicate they were uninsured due to ineligibility. Men were more likely than women to say they were uninsured because they did not need or want coverage.