RISE summarizes recent regulatory-related headlines.
CBO: Premiums will rise, millions will lose health insurance if ACA enhanced subsidy expires
The Congressional Budget Office (CBO) reports that failure to extend the expanded premium tax credit for another year or permanently will increase the number of people without health insurance and raise the average gross benchmark premiums for plans purchased through Affordable Care Act (ACA) marketplaces.
The expanded premium tax credit structure, provided by the American Recue Plan Act of 2021, reduced the cost of premiums of health insurance purchased through the marketplaces and extended eligibility to people whose incomes is above 400 percent of the federal poverty level. The subsidies were extended through calendar year 2025.
Without an extension through 2026, CBO estimates that the number of people without insurance will rise by 2.2 million. Without a permanent extension, CBO estimates, the number of uninsured people will increase by 3.7 million in 2027, and by 3.8 million, on average, in each year over the 2026-2034 period.
Gross benchmark premiums will increase by 4.3 percent, on average, without an extension through 2026. Without a permanent extension, those premiums will increase by 7.7 percent in 2027, and by 7.9 percent, on average, over the 2026-2034 period.
In response to the report, President Joe Biden said he urges Congress to continue the Affordable Care Act tax credits and protect affordable health insurance for millions of Americans.
“Health care should be a right, not a privilege, and every American should be able to access quality affordable coverage,” Biden said. “My Administration has worked tirelessly to make it happen, and our plan is working: premiums for health insurance through the Affordable Care Act are more affordable, Medicare and Medicaid are strong, seniors are paying less for prescription drugs, and more Americans have health insurance than ever before in American history.”
Anthem BCBS halts controversial plan to limit reimbursement of anesthesia
Anthem Blue Cross Blue Shield plans in Connecticut, New York, and Missouri have reversed a decision to limit reimbursement of anesthesia services during surgery and medical procedures. The insurer had announced plans to reimburse doctors based on pre-determined time limits beginning in February. Anesthesia is typically administered for as long as the procedure takes and payment is based on the time anesthesiologists deliver care preoperatively, during the operation, and when transitioning the patient to recovery units.
The proposed policy drew condemnation from the American Society of Anesthesiologists, which issued a news release calling the move a “money grab” and the “latest in a long line of appalling behavior by commercial health insurers looking to drive their profits up at the expense of patients and physicians providing essential care.”
Last week the insurer announced an update to the policy, stating that there was “significant widespread misinformation” about the anesthesia policy. Anthem said the proposed update was meant to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines. The insurer said any medically necessary anesthesia would have been paid under the update. If providers went beyond the clinical guidelines, they would have to submit medical documentation to support accurate payment.
“Based on feedback received and misinterpretation of our policy change, it is evident that our communication regarding this policy was not clear, and as a result, we have decided to not proceed with this policy change,” Anthem said.
HHS-OIG: Investigations, audits may lead to $7B in expected recoveries in FY2024
A new report reveals work by the Department of Health and Human Services (HHS), Office of Inspector General (OIG) could lead to recoupment of billions of dollars in misspent Medicare, Medicaid, and other health and human services.
The Fall 2024 Semiannual Report to Congress (SAR) highlights over $7 billion in expected recoveries and receivables resulting from HHS-OIG investigations and audits conducted during fiscal year 2024.
The report also highlights the following work:
Nursing homes: OIG reviewed 100 for-profit nursing homes nationwide and found that 24 did not meet federal requirements pertaining to infection preventionist, who are responsible for facility infection prevention and control. Based on its sample results, OIG estimates that 2,568 (approximately one in four) for-profit nursing homes nationwide may not have complied with federal requirements for infection preventionists during our review period. As a result, there may be increased health and safety risks for the residents and staff of these nursing homes.
Maternal health access in Medicaid Managed Care: OIG found that states could better leverage MCO provider coverage requirements and network adequacy standards to promote access to maternal health care. Specifically, OIG found that beyond obstetrician/gynecologist (OB/GYN) physicians and hospitals, many states reported they do not require MCOs to cover important types of maternal health providers and professionals, some of whose services are federally required. Some States are not using network adequacy standards to address important dimensions of maternal health care access.
Medicare improper payments: OIG found Medicare improperly paid hospitals an estimated $79 million for enrollees who had received mechanical ventilation. Hospitals attributed the improper billing to incorrectly counting the hours that enrollees had received mechanical ventilation or clerical errors in selecting procedure or diagnosis codes.