Health Plan Accountability Under the ACA FamiliesUSA Health Action 2016 February 5, 2016 Karen Pollitz, Senior Fellow Kaiser Family Foundation

Exhibit 1 Review Paper Certify health plans Review policy language Analyze provider network directory Review marketing materials Rate filing review Consumer tools: Summary of Benefits and Coverage Review Practice Complaints data Market conduct audits New transparency data reporting under ACA Accountability “On Paper” vs. “In Practice”

Exhibit 2 Health plans must periodically report data to the Secretary of HHS on: –Enrollment –Disenrollment –Claims payment practices –Number of claims denied –Cost sharing and payments for out-of-network claims –Periodic financial disclosures –Information on enrollee rights –Other information as determined appropriate by the Secretary HHS to share data with other federal and state insurance/health plan regulators Make data available to public in plain language Effective date: –September 2010 for plans outside Marketplace –January 2014 for Marketplace plans Source: Affordable Care Act, Section 1311(e) and Section 2715A Transparency Data Reporting Requirements Under ACA

Exhibit 3 Monitor stability of enrollment, disenrollment patterns –Overall –High-cost/high-claims individuals Monitor timeliness of claims payment/pre-authorization/denied claims –Overall –Specified conditions, treatments, procedures Monitor appeals of denied claims, resolution Monitor incidence and amount of out-of-network claims –Overall –High-cost conditions –Treatment settings (eg, “surprise” out of network bills) Monitor coverage for preventive services, waiver of cost sharing Develop plan ratings on –Claims “hassle” factor, network adequacy, other measures Potential Uses of Transparency Data

Exhibit 4 Vast Majorities Say Health Insurance Companies Should Be Transparent, And Most Say They Would Be Likely To Use Such Data NOTE: “Data use” question only asked of those who said health insurance companies should be required to publically report data. SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted September 17-23, 2015)

Exhibit 5 All ACA-compliant plans in non-group and small-group markets currently collect data monthly on: –Enrollment –Disenrollment –Paid claims Data reported at individual enrollee level, de-identified, by plan CMS accesses data via “edge server,” but uses only to administer premium stabilization subsidy programs for issuers (risk adjustment, reinsurance, risk- corridors) –99.7% of insurance issuers successfully submit the data needed to calculate plan payments * Data could also be used to satisfy some ACA transparency data requirements Source: “Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2014 Benefit Year,” Centers for Medicare & Medicaid Services, revised September 17, Burden on Health Insurance Issuers, Health Plans?