T HE A FFORDABLE C ARE A CT:   S YSTEMS & R EPORTING
O VERVIEW         •   Systems         •   Data Validation         •   Program Integrity         •   Financial Integrity   ...
SYSTEMSPAGE 3
S YSTEMS         •   Systems include both policies and procedures and             information technology systems (e.g., a ...
S YSTEMS :                 E LIGIBILITY AND E NROLLMENT         •   Exchanges must have a system in place that will both  ...
S YSTEMS :                 D ATA C OLLECTING            AND     P ROCESSING         •   ACA §4302 allows for data collecti...
S YSTEMS :                        F INANCIAL R EPORTING         •   In order to determine if an applicant is eligible for ...
S YSTEMS :                     F INANCIAL R EPORTING                 FOR                            TAX C REDITS         S...
S YSTEMS :                    E LECTRONIC HEALTH R ECORDS                              (EHR S )         •   EHRs are digit...
S YSTEMS :                  P RIVACY     AND     S ECURITY S TANDARDS          •   Exchanges are required to follow applic...
DATA VALIDATIONPAGE 11
D ATA VALIDATION :                                     A PPLICANT          Data validation for individual applicants by Ex...
D ATA VALIDATION :                               A PPLICANT          •   The proposed federal data services hub is expecte...
D ATA VALIDATION :                 E MPLOYER -S PONSORED C OVERAGE          Data validation for employer-sponsored coverag...
D ATA VALIDATION :              E MPLOYER -S PONSORED C OVERAGE          •   HHS expects the infrastructure for an authori...
D ATA VALIDATION :                                  R ISK A DJUSTMENTPlease refer   •   HHS proposed risk adjustment data ...
REPORTING REQUIREMENTSPAGE 17
R EPORTING R EQUIREMENTS :                          E NROLLMENT D ATA          Exchanges and health plan issuers must repo...
R EPORTING R EQUIREMENTS :                              I SSUER D ATA          Issuers in each state that offer the three ...
R EPORTING R EQUIREMENTS :                               F INANCIAL D ATA          ACA §1313 – Financial integrity        ...
KEY DATESPAGE 21
K EY D ATES :                           S YSTEMS & R EPORTING                    DATE                                     ...
K EY D ATES :                            S YSTEMS & R EPORTING                DATE                                      EV...
R EED & A SSOCIATES , CPA S          For more information on Reed & Associates, CPAs please                              c...
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The Affordable Care Act Part 4: Systems and Reporting

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The Affordable Care Act Part 4: Systems and Reporting

  1. 1. T HE A FFORDABLE C ARE A CT: S YSTEMS & R EPORTING
  2. 2. O VERVIEW • Systems • Data Validation • Program Integrity • Financial Integrity • Prevention of Fraud, Waste, and Abuse • Program Transparency • Reporting Requirements • Key DatesPAGE 2
  3. 3. SYSTEMSPAGE 3
  4. 4. S YSTEMS • 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 Enrollment o Data Collecting and Processing o Financial Reporting o Electronic Health Records (EHRs) o Privacy and Security StandardsPAGE 4
  5. 5. S YSTEMS : E LIGIBILITY AND E NROLLMENT • 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 portal o Be streamlined for simplicity o Determine eligibility for government sponsored healthcare/tax benefits o Communicate with other systems, such as CMS and IRS databasesPAGE 5
  6. 6. S YSTEMS : D ATA C OLLECTING AND P ROCESSING • ACA §4302 allows for data collection in order to determine health care disparities and demographics o Race and ethnicity, gender, primary language, and disability status are the types of data collected o 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 processingPAGE 6
  7. 7. S YSTEMS : F INANCIAL R EPORTING • 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 electronicallyPAGE 7
  8. 8. S YSTEMS : F INANCIAL R EPORTING FOR TAX C REDITS Small Business Health Care Tax Credit o 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 Credit o Individuals need to report income information, family size, and information on changes in circumstancesPAGE 8
  9. 9. S YSTEMS : E LECTRONIC HEALTH R ECORDS (EHR S ) • 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 informationPAGE 9
  10. 10. S YSTEMS : P RIVACY AND S ECURITY S TANDARDS • 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, and o Requirements that health plans certify compliance with all HIPAA standards and operating rulesPAGE 10
  11. 11. DATA VALIDATIONPAGE 11
  12. 12. D ATA VALIDATION : A PPLICANT 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 eligibilityPAGE 12
  13. 13. D ATA VALIDATION : A PPLICANT • 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.”PAGE 13
  14. 14. D ATA VALIDATION : E MPLOYER -S PONSORED C OVERAGE 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 AdministrationPAGE 14
  15. 15. D ATA VALIDATION : E MPLOYER -S PONSORED C OVERAGE • 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.PAGE 15
  16. 16. D ATA VALIDATION : R ISK A DJUSTMENTPlease refer • HHS proposed risk adjustment data validation process will to our include the following steps: previous piece on 1. Sample Selection Risk and 2. Initial Validation AuditReinsurance 3. Second Validation Audit for moreinformation 4. Error Estimation on the Risk 5. AppealsAdjustment 6. Payment Adjustments Programs. • After data validation, the state/HHS will be able to adjust the average actuarial risk of each plan or payments/charges PAGE 16 based on risk changes
  17. 17. REPORTING REQUIREMENTSPAGE 17
  18. 18. R EPORTING R EQUIREMENTS : E NROLLMENT D ATA 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 • Employers o Employer name, address and contact information o Employee roster and number of employees • EmployeesPAGE 18 o Name, address, contact information, DOB, dependent information
  19. 19. R EPORTING R EQUIREMENTS : I SSUER D ATA 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 enrollmentPAGE 19
  20. 20. R EPORTING R EQUIREMENTS : F INANCIAL D ATA 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 bePAGE 20 published by health plans
  21. 21. KEY DATESPAGE 21
  22. 22. K EY D ATES : S YSTEMS & R EPORTING 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 Annual reports on physician payments due to HHS from and on the 90th day manufacturers for the previous year. of every year following 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.PAGE 22
  23. 23. K EY D ATES : S YSTEMS & R EPORTING 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.PAGE 23
  24. 24. R EED & A SSOCIATES , CPA S For more information on Reed & Associates, CPAs please contact us at: inquire@reedassociatescpas.com Phone: 860-395-1996 Or visit our website: reedassociatescpas.comPAGE 24 Quality. Integrity. Experience.

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