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Feds ask insurers about enrollee steering

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Officials at the Centers for Medicare & Medicaid Services (CMS) said today that they want to act quickly on one of Aetna’s complaints about the Affordable Care Act exchange system: that providers are shifting very sick patients into public health insurance exchange plans, from Medicaid plans or Medicare plans, to push up their own reimbursement rates.

CMS, the arm of the U.S. Department of Health and Human Services in charge of overseeing the ACA public exchange system, is preparing to publish a call for information about inappropriate steering of Medicare and Medicaid plan enrollees into ACA exchange plans.

A draft of the call for information is already in the Federal Register publication system. The official publication date will be Aug. 23.

Comments will be due 30 days after the official publication date.

The ACA now limits health insurers’ ability to use individual health information when deciding whether to issue coverage, and bans use of health information other than age and tobacco use when issuers are pricing the coverage.

That means that, during the regular open enrollment period, even people who need organ transplants or kidney dialysis can get the same coverage for the same price as other people.

Ordinary consumers and providers may feel as if helping sick people pay for private health coverage is a kind thing to do, but insurers believe that special efforts to help very sick people, and only very sick people, pay for coverage conflicts with the idea that the country should be encouraging all people, including young, healthy people, to get covered.

Related: Celgene accused of using charities in ‘scheme to gain billions’

Insurers are especially critical of patient premium support efforts that might encourage the enrollees to use specific expensive hospitals, or specific expensive drugs.

(Photo: Douglas Healey/AP)

Aetna Chairman Mark Bertolini talked about the steering issue recently during Aetna’s second-quarter earnings call with securities analysts. (Photo: Douglas Healey/AP Photo)

What Aetna’s chairman said

Earlier this month, when Aetna Chairman Mark Bertolini discussed the company’s poor second-quarter exchange program performance with securities analysts, he complained about patient steering.

“We now believe we have third parties paying premiums for special interest groups, both in small group and individual, that are supporting people getting access to these services,” Bertolini said.

Related: 3 ways Aetna just shook the ACA’s foundations

In the new call for information, CMS says that, if the allegations are true, inappropriate patient steering could increase overall health system costs and also hurt patient care, by disrupting patient care coordination and exposing sick, low-income patients to much higher out-of-pocket costs.

Officials are asking commenters to talk about how they think providers are steering patients into the exchange system, how steering is affecting the individual health market risk pool, and if issuers think there’s anything CMS can do to help issuers tell when providers or provider-affiliated organizations are helping enrollees pay their premiums.

Officials also ask if CMS could do anything to change Medicaid and Medicare provider rules that could cut down on inappropriate steering.


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