Impact of Continued Biased Disenrollment from the Medicare Advantage Program to Fee-for-Service

By Gerald F. Riley
Centers for Medicare & Medicaid Services, Medicare & Medicaid Research Review , 2012: Volume 2, Number 4
Background: Medicare managed care enrollees who disenroll to fee-for-service (FFS) historically have worse health and higher costs than continuing enrollees and beneficiaries remaining in FFS.
Objective: To examine disenrollment patterns by analyzing Medicare payments following disenrollment from Medicare Advantage (MA) to FFS in 2007. Recent growth in the MA program, introduction of limits on timing of enrollment/disenrollment, and initiation of prescription drug benefits may have substantially changed the dynamics of disenrollment.
Conclusions: Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries, raising concerns about care experiences among sicker enrollees and increased costs to Medicare.
Discussion
Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries. Disenrollees had higher risk scores and incurred higher risk-adjusted payments than beneficiaries in FFS. Their high risk scores are in contrast to the risk scores of the general MA population, most of which is enrolled in plans with average risk scores similar to or less than local FFS experience (United States Government Accountability Office, 2010). Recent studies have also shown that MA plans continue to experience favorable selection through enrollment of low-cost beneficiaries (MedPAC, 2012; Riley, 2012). These research findings suggest a pattern of selective disenrollment whereby disenrollees are sicker and more expensive than the beneficiaries who remain enrolled in MA plans. This selective disenrollment potentially increases Medicare costs through the return of high-cost beneficiaries to the FFS sector, leaving behind a healthier and lower-cost population in the capitated MA sector.
The Affordable Care Act mandated changes to MA payment methods that will result in significant decreases in payment rates and bring them closer in line with plan costs. This may intensify pressure on plans to encourage selective disenrollment.
Disenrollees from PPOs and PFFS plans incurred lower payments post-disenrollment than disenrollees from HMOs and similar types of plans, and their average payments were closer to predicted levels. Possible explanations include a less chronically ill disenrollee population from PPO and PFFS plans, or less unmet demand for services when they transitioned to FFS. Less selective disenrollment from PPO and PFFS plans may be attributable to the more extensive network of providers available under these types of plans. Beneficiaries with chronic illnesses have a greater choice of physicians to manage their conditions and have more opportunities to switch providers if they become dissatisfied with their care. This expanded choice of providers may reduce the incentives for chronically ill enrollees to leave these types of plans.
http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MMRR/Do…

Earlier studies of the Medicare + Choice plans and more recent studies of the successor Medicare Advantage plans have shown that, when it comes to managed care, the healthy go in and the sick come out. Taxpayers are paying more for the healthier, less-costly patients who are enrolled in the Medicare Advantage plans, and then pay more for the sicker patients who return to the traditional Medicare program (adverse selection). This CMS study adds to that evidence.
One interesting finding in this study is that those enrolled in PPO or FFS Medicare Advantage plans did not show as great post-enrollment cost increases. It is likely that the patients did not experience as much of a limitation in services in PPO plans, such as those offered by Blue Cross and Blue Shield, since their networks tend to include a much larger percentage of the physician population.
There are two important take-home points here. One is that we should stop wasting taxpayer funds on both the excesses of the Medicare Advantage plans, and the costly adverse selection burden that they place on the traditional Medicare program.
The other point is that we should reject the policies of the private insurance sector that is taking away our health care choices by establishing networks of health care providers. Our traditional Medicare program includes a choice of any provider, except for the rare physician who totally opts out of the Medicare program.
For greater economy and expanded choice, we should change to a program of an improved Medicare for everyone.

AHIP (America’s Health Insurance Plans), February 1, 2013

A new report from America’s Health Insurance Plans (AHIP) highlighting data collected by Dyckman & Associates shows that some physicians who choose not to participate in health insurance networks are charging patients fees that are 10 times – and in some cases, nearly 100 times – Medicare reimbursement for the same service in the same geographic area. Looking at the 30 largest states, the report found that some physicians who do not take insurance are charging patients startling fees for a wide variety of medical treatments and services.

This report demonstrates the importance of public policy leaders focusing on how much patients who seek out-of-network care are being charged by some physicians. In discussions to date, the focus only has been on how much insurers pay for these services, and the critical issue of what out-of-network physicians charge patients has been ignored.

The findings of the report should cause policymakers to closely investigate this issue, especially considering how these charges compare to in-network fees, as well as fees charged for similar services in other countries. For example, in New York, a physician billed a patient $115,625 for lumbar spinal fusion – 62 times the Medicare fee of $1,867.

While the issue of how much is appropriate for out-of-network physicians to charge has not been part of the affordability discussion to date, this report demonstrates that it needs to be. No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.

“As we shine a spotlight on the affordability issue, we encourage policymakers to look at how much is being charged for services, particularly since there is often no relationship between higher charges and higher quality of care,” said AHIP President and CEO Karen Ignagni. “With the nation facing the crushing burden of rising medical costs, all stakeholders should be focusing on constructive ways to bring costs under control.”

https://www.ahip.org/News/Press-Room/2013/New-Report-Examines-Physician-Out-of-Network-Charges.aspx

AHIP infographic on highest out-of-network charges:
http://www.ahipcoverage.com/wp-content/uploads/2013/01/OutOfNetwork_National_V17_FV.jpg

Comment:

By Don McCanne, M.D.

The insurance lobby organization, AHIP, is correct when they point out that patients are not protected from exorbitant fees charged by physicians outside of their own insurance networks. Although this report appropriately condemns outrageous fee gouging, the report itself is deceptive, reflecting on AHIP’s own credibility.

AHIP asked its insurers to provide the three highest billed charges from non-participating providers for each of 24 CPT procedure codes. They then took the very highest charge for 10 procedures and created a graph demonstrating how outrageous these charges were compared to Medicare rates. They distributed the graph with their press release.

Although the bar graph is quite impressive (link above), it represents only ten specific instances of fee gouging. Yet the infographic – labeled “Out-of-Network Charges” – is presented as if it were representative of charges made by out-of-network providers (though it does state that these are the highest reported out-of-network provider charges).

Nowhere in the 26 page report is there any mention of what fees were actually paid. Although the insurer pays no more than its allowed out-of-network charges, if any, does the patient pay the rest? No. Often the patients are able to negotiate payments that are closer to typical commercial insurance rates. Sometimes the patient simply doesn’t pay at all, though the claim may be turned over to a collection agency. Regardless, the AHIP report is deceptive since it represents only a few outrageous billing charges but does not represent actual typical out-of-network payments.

In this press release, AHIP implies that there needs to be a mechanism “to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.” In essence, they are saying that the government should require out-of-network providers to accept rates similar to those agreed to through contracts with the in-network providers.

Think about that. The only mechanism that insurers have introduced to slow the increase in heath care spending has been provider contracting. Okay. Let’s accept their implicit recommendation. Let’s do what other industrialized nations do and use some form of government administered pricing. Then there would be no reason for the insurers to establish exclusive provider networks.

Since the insurers then would have nothing substantial to offer other than claims processing, we can do away with much of their administrative and marketing waste. In fact, we can do away with them completely by establishing our own universal health insurance administrator – a single payer national health program.

As AHIP CEO Karen Ignagni says, “With the nation facing the crushing burden of rising medical costs, all stakeholders should be focusing on constructive ways to bring costs under control.” She’s right. The first step should be to get rid of the private insurers.

By Brett Norman
POLITICO, January 29, 2013

When the health exchanges open next year, they will cover some of the sickest and costliest patients, people who cannot easily get insurance precisely because they are so likely to run up bills that no insurer would want to be on the hook for.

The federal health law contains several measures designed to spread the risk and tamp down some of the expected turbulence in the market. But a recent change in how the Department of Health and Human Services plans to run a three-year, $20 billion fund — known as reinsurance — to cushion health plans that end up with lots of high-cost customers is forcing states to rethink their own timetable for shifting some of their highest-risk people into the exchanges.

The fear, of course, is that if all the sick people flood the exchanges and younger, healthier ones hold back, premiums could surge. The health law has a bunch of mechanisms to try to avert rate shock — but questions remain about how well they will work.

More than 300,000 people are now covered through special plans for people with pre-existing conditions — about 100,000 in pools created by the health law and more than 200,000 in older, state-run pools.

The federal plan was designed from the start to be temporary and to shut down as soon as the exchanges open.

But many states had planned on moving their high-risk pool populations into the exchanges slowly to mitigate the shock to the individual market. But now, the state high-risk pools may offload as many people as they can onto the exchanges as soon as they open in 2014 or risk losing a piece of that $20 billion pie.

The Affordable Care Act program requires all insurers to pay into the reinsurance fund — and to be paid out of it if they have a big share of really expensive customers in the individual market. State officials had anticipated having a voice in distributing those payments to hard-hit plans in their states, but HHS in December proposed that it would give the money to plans with enrollees that cost more than $60,000 per year. And state high-risk pools wouldn’t be eligible for the cash.

The reinsurance program is front-loaded, with $10 billion in the first year, $6 billion in the second and $4 billion in the third and final year. By year three, the hope is that a broad range of people will be in the state exchanges, balancing out the really high-cost patients.

“I don’t think it’s going to be enough — it will offset some but not all of the effect of the high-risk pools on the individual market,” said Jonathan Gruber, an MIT economist who has studied the issue in several states.

http://www.politico.com/story/2013/01/states-rethink-high-risk-pools-exchanges-86831.html

And…

HHS Risk Adjustment Model Algorithm Instructions

Centers for Medicare and Medicaid Services
The Center for Consumer Information & Insurance Oversight

Section 1343 of the Affordable Care Act provides for a permanent risk adjustment program. To protect against potential effects of adverse selection, the risk adjustment program transfers funds from plans with relatively lower-risk enrollees to plans with relatively higher-risk enrollees. It generally applies to non-grandfathered individual and small group plans inside and outside Exchanges.

The methodology that HHS proposes to use when operating a risk adjustment program on behalf of a State would calculate a plan average risk score for each covered plan based upon the relative risk of the plan’s enrollees, and apply a payment transfer formula in order to determine risk adjustment payments and charges between plans within a risk pool within a market within a State. The proposed risk adjustment methodology addresses three considerations: (1) the newly insured population; (2) plan metal level differences and permissible rating variation; and (3) the need for risk adjustment transfers that net to zero.

The proposed risk adjustment methodology developed by HHS:

• Is developed on commercial claims data for a population similar to the expected population to be risk adjusted;
• Employs the hierarchical condition category (“HCC”) grouping logic used in the Medicare risk adjustment program, with HCCs refined and selected to reflect the expected risk adjustment population;
• Establishes concurrent risk adjustment models, one for each combination of metal level (platinum, gold, silver, bronze, catastrophic) and age group (adult, child, infant);
• Results in payment transfers that net to zero within a risk pool within a market within a State; 
• Adjusts payment transfers for plan metal level, geographic rating area, induced demand, and age rating, so that transfers reflect health risk and not other cost differences; and
• Transfers funds between plans within a risk pool within a market within a State.

This document provides the detailed information needed to calculate risk scores given individual diagnoses. (The report then goes into 14 pages describing the algorithm for the HHS-Hierarchical Condition Categories risk adjustment model.)

http://cciio.cms.gov/resources/files/ra_instructions_proposed_1_2013.pdf

Comment:

By Don McCanne, M.D.

In a single payer financing system, health care is simply paid for out of a publicly-financed, single risk pool that covers everyone, regardless of how much appropriate health care is provided to each individual.

In our current fragmented financing system, risk pools are segregated and thus are each vulnerable to an influx of high-cost patients (adverse selection). The spending on an excess of high-cost patients drives premiums up ever higher until they are no longer affordable, patients drop out, and the insurer must then shut down (death spiral).

To protect against excessive costs being borne by any single risk pool, policies have been established to cover patients who have preexisting disorders, to provide reinsurance for costs exceeding defined limits, and to transfer funds from risk pools that enrolled healthier patients to risk pools that cover more high-cost patients.

When the Affordable Care Act (ACA) was written, it was recognized that many people with preexisting conditions could not purchase insurance because the insurers wanted to keep their premiums competitive, so they refused to accept these patients. For that reason, a temporary three-year program was established to provide subsidies to new risk pools that concentrated patients with preexisting disorders. Only about 100,000 people were enrolled since the premiums were still unaffordable for many who would otherwise qualify, plus there were restrictions such as a requirement to be uninsured for at least 6 months.

Although these pools for those with preexisting disorders didn’t work very well, at least these individuals would be able to participate in the state insurance exchanges once they become operative next January 1, since ACA requires that every qualified person be accepted regardless of prior conditions (guaranteed issue).

A problem is that adding high-cost patients will drive premiums up, perhaps to a level that could precipitate a death spiral. It was thought that this would be a problem only initially, since later on the pools would be filled with younger, healthier patients who could absorb the higher costs of the sicker patients (a very dubious assumption which we will not address here).

Since this was thought to be a temporary problem, the authors of ACA added another special three-year program – a reinsurance scheme. For any enrollee whose costs exceed $60,000 per year, the government would pick up the balance. Many believe that the $20 billion to be authorized over the three years of the p
rogram is not enough to cover the anticipated need.

Well, by the time that plan is terminated, there will have been established a permanent plan to address this problem of unequal distribution of risk between these segregated risk pools – a risk adjustment scheme. This is to be done through the HHS-Hierarchical Condition Categories risk adjustment model mentioned above.

It should be pointed out that a fairly recent study of the Hierarchical Condition model used for Medicare Advantage plans has demonstrated that the private insurers have already learned how to game the system, making patients appear much more ill than they really are (NBER Working Paper No. 16977, April 2011).

It’s too bad since, by enacting a single payer system, Congress could have eliminated the need for temporary high-risk pools, the need for temporary reinsurance, and, especially, the need for risk adjustment schemes which the private insurers will always manipulate to their own advantage.

You might want to click on the link to the HHS Risk Adjustment Model Algorithm (above) and skim through the pages just to get a feeling of the complexity of the risk adjustment process. Better yet, click on the following link and in one picture you’ll understand how the process really works:

http://www.kaiserhealthnews.org/cartoons/2013/January/Risk-Factor.aspx

States rethink high-risk-pool plans

By Brett Norman
POLITICO, January 29, 2013
When the health exchanges open next year, they will cover some of the sickest and costliest patients, people who cannot easily get insurance precisely because they are so likely to run up bills that no insurer would want to be on the hook for.
The federal health law contains several measures designed to spread the risk and tamp down some of the expected turbulence in the market. But a recent change in how the Department of Health and Human Services plans to run a three-year, $20 billion fund — known as reinsurance — to cushion health plans that end up with lots of high-cost customers is forcing states to rethink their own timetable for shifting some of their highest-risk people into the exchanges.
The fear, of course, is that if all the sick people flood the exchanges and younger, healthier ones hold back, premiums could surge. The health law has a bunch of mechanisms to try to avert rate shock — but questions remain about how well they will work.
More than 300,000 people are now covered through special plans for people with pre-existing conditions — about 100,000 in pools created by the health law and more than 200,000 in older, state-run pools.
The federal plan was designed from the start to be temporary and to shut down as soon as the exchanges open.
But many states had planned on moving their high-risk pool populations into the exchanges slowly to mitigate the shock to the individual market. But now, the state high-risk pools may offload as many people as they can onto the exchanges as soon as they open in 2014 or risk losing a piece of that $20 billion pie.
The Affordable Care Act program requires all insurers to pay into the reinsurance fund — and to be paid out of it if they have a big share of really expensive customers in the individual market. State officials had anticipated having a voice in distributing those payments to hard-hit plans in their states, but HHS in December proposed that it would give the money to plans with enrollees that cost more than $60,000 per year. And state high-risk pools wouldn’t be eligible for the cash.
The reinsurance program is front-loaded, with $10 billion in the first year, $6 billion in the second and $4 billion in the third and final year. By year three, the hope is that a broad range of people will be in the state exchanges, balancing out the really high-cost patients.
“I don’t think it’s going to be enough — it will offset some but not all of the effect of the high-risk pools on the individual market,” said Jonathan Gruber, an MIT economist who has studied the issue in several states.
http://www.politico.com/story/2013/01/states-rethink-high-risk-pools-exc…
And…

HHS Risk Adjustment Model Algorithm Instructions

Centers for Medicare and Medicaid Services
The Center for Consumer Information & Insurance Oversight
Section 1343 of the Affordable Care Act provides for a permanent risk adjustment program. To protect against potential effects of adverse selection, the risk adjustment program transfers funds from plans with relatively lower-risk enrollees to plans with relatively higher-risk enrollees. It generally applies to non-grandfathered individual and small group plans inside and outside Exchanges.
The methodology that HHS proposes to use when operating a risk adjustment program on behalf of a State would calculate a plan average risk score for each covered plan based upon the relative risk of the plan’s enrollees, and apply a payment transfer formula in order to determine risk adjustment payments and charges between plans within a risk pool within a market within a State. The proposed risk adjustment methodology addresses three considerations: (1) the newly insured population; (2) plan metal level differences and permissible rating variation; and (3) the need for risk adjustment transfers that net to zero.
The proposed risk adjustment methodology developed by HHS:
• Is developed on commercial claims data for a population similar to the expected population to be risk adjusted;
• Employs the hierarchical condition category (“HCC”) grouping logic used in the Medicare risk adjustment program, with HCCs refined and selected to reflect the expected risk adjustment population;
• Establishes concurrent risk adjustment models, one for each combination of metal level (platinum, gold, silver, bronze, catastrophic) and age group (adult, child, infant);
• Results in payment transfers that net to zero within a risk pool within a market within a State;
• Adjusts payment transfers for plan metal level, geographic rating area, induced demand, and age rating, so that transfers reflect health risk and not other cost differences; and
• Transfers funds between plans within a risk pool within a market within a State.
This document provides the detailed information needed to calculate risk scores given individual diagnoses. (The report then goes into 14 pages describing the algorithm for the HHS-Hierarchical Condition Categories risk adjustment model.)
http://cciio.cms.gov/resources/files/ra_instructions_proposed_1_2013.pdf

In a single payer financing system, health care is simply paid for out of a publicly-financed, single risk pool that covers everyone, regardless of how much appropriate health care is provided to each individual.
In our current fragmented financing system, risk pools are segregated and thus are each vulnerable to an influx of high-cost patients (adverse selection). The spending on an excess of high-cost patients drives premiums up ever higher until they are no longer affordable, patients drop out, and the insurer must then shut down (death spiral).
To protect against excessive costs being borne by any single risk pool, policies have been established to cover patients who have preexisting disorders, to provide reinsurance for costs exceeding defined limits, and to transfer funds from risk pools that enrolled healthier patients to risk pools that cover more high-cost patients.
When the Affordable Care Act (ACA) was written, it was recognized that many people with preexisting conditions could not purchase insurance because the insurers wanted to keep their premiums competitive, so they refused to accept these patients. For that reason, a temporary three-year program was established to provide subsidies to new risk pools that concentrated patients with preexisting disorders. Only about 100,000 people were enrolled since the premiums were still unaffordable for many who would otherwise qualify, plus there were restrictions such as a requirement to be uninsured for at least 6 months.
Although these pools for those with preexisting disorders didn’t work very well, at least these individuals would be able to participate in the state insurance exchanges once they become operative next January 1, since ACA requires that every qualified person be accepted regardless of prior conditions (guaranteed issue).
A problem is that adding high-cost patients will drive premiums up, perhaps to a level that could precipitate a death spiral. It was thought that this would be a problem only initially, since later on the pools would be filled with younger, healthier patients who could absorb the higher costs of the sicker patients (a very dubious assumption which we will not address here).
Since this was thought to be a temporary problem, the authors of ACA added another special three-year program – a reinsurance scheme. For any enrollee whose costs exceed $60,000 per year, the government would pick up the balance. Many believe that the $20 billion to be authorized over the three years of the program is not enough to cover the anticipated need.
Well, by the time that plan is terminated, there will have been established a permanent plan to address this problem of unequal distribution of risk between these segregated risk pools – a risk adjustment scheme. This is to be done through the HHS-Hierarchical Condition Categories risk adjustment model mentioned above.
It should be pointed out that a fairly recent study of the Hierarchical Condition model used for Medicare Advantage plans has demonstrated that the private insurers have already learned how to game the system, making patients appear much more ill than they really are (NBER Working Paper No. 16977, April 2011).
It’s too bad since, by enacting a single payer system, Congress could have eliminated the need for temporary high-risk pools, the need for temporary reinsurance, and, especially, the need for risk adjustment schemes which the private insurers will always manipulate to their own advantage.
You might want to click on the link to the HHS Risk Adjustment Model Algorithm (above) and skim through the pages just to get a feeling of the complexity of the risk adjustment process. Better yet, click on the following link and in one picture you’ll understand how the process really works:
http://www.kaiserhealthnews.org/cartoons/2013/January/Risk-Factor.aspx

Centers for Medicare and Medicaid Services
January 30, 2013

Under the Affordable Care Act, the Federal government, State governments, insurers, employers, and individuals are given shared responsibility to reform and improve the availability, quality, and affordability of health insurance coverage in the United States. Starting in 2014, the individual shared responsibility provision calls for each individual to have basic health insurance coverage (known as minimum essential coverage), qualify for an exemption, or make a shared responsibility payment when filing a federal income tax return.

Highlights of the Proposed Regulations

A principle in implementing the individual shared responsibility provision is that the shared responsibility payment should not apply to any taxpayer for whom coverage is unaffordable, who has other good cause for going without coverage, or who goes without coverage for only a short time.  The proposed regulations include several rules to implement this principle.

For example:

Hardship Exemption Clarified to Protect Taxpayers, Address Key Concerns

The statute gives HHS authority to exempt individuals determined to “have suffered a hardship with respect to the capability to obtain coverage.”  In developing these proposed regulations, HHS considered several particular circumstances that provide good cause to go without coverage.  To provide clarity for taxpayers facing these circumstances, the HHS proposed regulations enumerate several situations that will always be treated as constituting a hardship and therefore allow for an exemption.  Hardship exemptions include:

* Individuals whom an Exchange projects will have no offer of affordable coverage (even if, due to a change in circumstance during the year, it turns out that the coverage would have been affordable).  This rule will protect individuals who turn down coverage because the Exchange projects it will be unaffordable but whose actual income for the year turns out to be higher so they are not eligible for the affordability exemption;

* Certain individuals who are not required to file an income tax return but who technically fall outside the statutory exemption for those with household income below the filing threshold; and

* Individuals who would be eligible for Medicaid but for a state’s choice not to expand Medicaid eligibility.  This rule will protect individuals in states that, pursuant to the Supreme Court decision, choose not to expand Medicaid eligibility.
 
The HHS regulations also provide that the hardship exemption will be available on a case-by-case basis for individuals who face other unexpected personal or financial circumstances that prevent them from obtaining coverage.
 
Specific Rules and Process for Receiving an Exemption

The proposed regulations also codify the statute’s nine categories of individuals who are exempt from the shared responsibility payment. These categories are as follows:

Individuals who cannot afford coverage;
Taxpayers with income below the filing threshold;
Members of Indian tribes;
Hardship;
Individuals who experience short coverage gaps.
Religious conscience;
Members of a health care sharing ministry;
Incarcerated individuals; and
Individuals who are not lawfully present.

http://www.cms.gov/apps/media/fact_sheets.asp (Select the Fact Sheet on “Individual Shared Responsibility…” dated January 30, 2013.)

Comment:

By Don McCanne, M.D.

Today CMS and the IRS released two sets of proposed rules which included the exemptions that will be allowed to avoid having to pay a penalty for not being insured.

Basically, the exempt individuals will be those for whom there are no affordable plans, those whose income falls below the threshold for filing tax returns, or those who would qualify for Medicaid under federal law but their state elected not to expand eligibility. A few other exemptions are listed in the excerpts above.

One concern in the actual rule (though not listed in the CMS Fact Sheet) is that the exemption for individuals who would otherwise have to pay more than 9.5% of their income for their share of the premium of an employer-sponsored plan applies only to the employee’s coverage, but not to coverage of the family members as well. At today’s premiums, this means that an employee could pay much more than 9.5% of income if the family were to be included under the employer-sponsored plan, and that would be just for the premiums. The deductibles and other cost sharing would be in addition.

It is interesting that, instead of calling the penalty for being uninsured a tax or a fine, CMS now calls it a “shared responsibility payment,” a payment to be made when filing a federal income tax return. It is ironic that this shared responsibility payment buys you… nothing!

With all of the administrative waste that characterizes our health care system, this rule adds even more administration complexity by providing opportunities to allow individuals to remain uninsured. And the reward is, if they qualify, they don’t have to make a shared responsibility payment. Hurray!

What happened to the reform advocates who were trying to advance policies that would ensure that everyone was covered? Didn’t they have a say in this process? Oh, that’s right. Sen. Baucus had them arrested.

Fact Sheet: Individual Shared Responsibility for Health Insurance Coverage and Minimum Essential Coverage Proposed Rules

Centers for Medicare and Medicaid Services
January 30, 2013
Under the Affordable Care Act, the Federal government, State governments, insurers, employers, and individuals are given shared responsibility to reform and improve the availability, quality, and affordability of health insurance coverage in the United States. Starting in 2014, the individual shared responsibility provision calls for each individual to have basic health insurance coverage (known as minimum essential coverage), qualify for an exemption, or make a shared responsibility payment when filing a federal income tax return.
Highlights of the Proposed Regulations
A principle in implementing the individual shared responsibility provision is that the shared responsibility payment should not apply to any taxpayer for whom coverage is unaffordable, who has other good cause for going without coverage, or who goes without coverage for only a short time.  The proposed regulations include several rules to implement this principle.
For example:
Hardship Exemption Clarified to Protect Taxpayers, Address Key Concerns
The statute gives HHS authority to exempt individuals determined to “have suffered a hardship with respect to the capability to obtain coverage.”  In developing these proposed regulations, HHS considered several particular circumstances that provide good cause to go without coverage.  To provide clarity for taxpayers facing these circumstances, the HHS proposed regulations enumerate several situations that will always be treated as constituting a hardship and therefore allow for an exemption.  Hardship exemptions include:
* Individuals whom an Exchange projects will have no offer of affordable coverage (even if, due to a change in circumstance during the year, it turns out that the coverage would have been affordable).  This rule will protect individuals who turn down coverage because the Exchange projects it will be unaffordable but whose actual income for the year turns out to be higher so they are not eligible for the affordability exemption;
* Certain individuals who are not required to file an income tax return but who technically fall outside the statutory exemption for those with household income below the filing threshold; and
* Individuals who would be eligible for Medicaid but for a state’s choice not to expand Medicaid eligibility.  This rule will protect individuals in states that, pursuant to the Supreme Court decision, choose not to expand Medicaid eligibility.
The HHS regulations also provide that the hardship exemption will be available on a case-by-case basis for individuals who face other unexpected personal or financial circumstances that prevent them from obtaining coverage.
Specific Rules and Process for Receiving an Exemption
The proposed regulations also codify the statute’s nine categories of individuals who are exempt from the shared responsibility payment. These categories are as follows:
Individuals who cannot afford coverage;
Taxpayers with income below the filing threshold;
Members of Indian tribes;
Hardship;
Individuals who experience short coverage gaps.
Religious conscience;
Members of a health care sharing ministry;
Incarcerated individuals; and
Individuals who are not lawfully present.
http://www.cms.gov/apps/media/fact_sheets.asp (Select the Fact Sheet on “Individual Shared Responsibility…” dated January 30, 2013.)

Today CMS and the IRS released two sets of proposed rules which included the exemptions that will be allowed to avoid having to pay a penalty for not being insured.
Basically, the exempt individuals will be those for whom there are no affordable plans, those whose income falls below the threshold for filing tax returns, or those who would qualify for Medicaid under federal law but their state elected not to expand eligibility. A few other exemptions are listed in the excerpts above.
One concern in the actual rule (though not listed in the CMS Fact Sheet) is that the exemption for individuals who would otherwise have to pay more than 9.5% of their income for their share of the premium of an employer-sponsored plan applies only to the employee’s coverage, but not to coverage of the family members as well. At today’s premiums, this means that an employee could pay much more than 9.5% of income if the family were to be included under the employer-sponsored plan, and that would be just for the premiums. The deductibles and other cost sharing would be in addition.
It is interesting that, instead of calling the penalty for being uninsured a tax or a fine, CMS now calls it a “shared responsibility payment,” a payment to be made when filing a federal income tax return. It is ironic that this shared responsibility payment buys you… nothing!
With all of the administrative waste that characterizes our health care system, this rule adds even more administration complexity by providing opportunities to allow individuals to remain uninsured. And the reward is, if they qualify, they don’t have to make a shared responsibility payment. Hurray!
What happened to the reform advocates who were trying to advance policies that would ensure that everyone was covered? Didn’t they have a say in this process? Oh, that’s right. Sen. Baucus had them arrested.