1. Congress 

Sen. Grassley Urges Trump to Increase Importation of Drugs

On Dec 13, Sen. Charles Grassley (R-IA) urged President-elect Donald Trump to use agency authority to increase the importation of drugs from other countries to help bring down the cost of drugs in the United States. He also suggested the Centers for Medicare and Medicaid Services (CMS) and the Food and Drug Administration (FDA) could do more to help control drug prices. Grassley also said the Federal Trade Commission (FTC) needs to step up its scrutiny of the pharmaceutical market.

Grassley noted Trump’s recent discussion with Time, in which the president-elect said he was going to bring down drug prices. In his letter, Grassley said he shares those concerns, adding that a “lack of drug options in the marketplace, drug company anti-competitive behavior, regulatory backlogs at the Food and Drug Administration (FDA), inefficient and ineffective government bureaucracies, and poor corporate decisions have all contributed to the current crisis.”

He cited Mylan’s EpiPen, Turing Pharmaceuticals’ AIDS drug Daraprim and Valeant Pharmaceuticals’ heart drug Isuprel as examples of extreme price spikes. EpiPen’s 400 percent increase, from $52 to $600 since 2007, drew widespread consumer frustration. Grassley, who chairs the Senate Judiciary Committee, is looking into Mylan’s classification of EpiPen as a generic, which cost Medicaid hundreds of millions of dollars in rebates.

Grassley asked the incoming administration to work with lawmakers on legislation to address anti-competitive behavior and reduce regulatory burdens. Grassley also asked Trump to cooperate more fully with congressional requests than has been the case with the Obama administration, and noted that CMS and the Justice Department would not testify at a hearing on Mylan and EpiPens that Grassley had planned.

Finance Republicans Seek Input on Future of Medicaid in Letter to Republican Governors Association

In a Dec. 13 letter, Senate Finance Committee Republicans requested input from Republican governors on how to provide states with the flexibility to design and operate innovative Medicaid programs in a fiscally responsible way. The letter, led by Chairman Orrin Hatch (R-UT), was sent to the Republican Governors Association, and announced the committee will convene a roundtable discussion in January 2017 with state governors on the future of the Medicaid program.

“Even before the most recent expansion resulting from the Affordable Care Act (ACA), the Medicaid program was plagued by quality issues, states were stymied in their attempts to utilize innovative solutions to improve patient care, and both federal and state Medicaid spending was growing at unprecedented, and unsustainable levels,” the senators wrote. “We now find ourselves uniquely positioned to repeal the ACA, which was rife with failures and the broken promise of lowering health care costs for the American people, and advance alternatives to it. … In addition, we recognize that we have the opportunity to reflect on flexibilities that states have gained in recent years as well as the factors that inhibit states from pursuing innovations and responding to the unique needs of their Medicaid beneficiaries. To that end, we will convene a small roundtable of Governors in January 17, to begin the important dialogue regarding the future of the Medicaid program.”

The letter was signed by Senate Finance Committee Chairman Orrin Hatch (UT) and Senators Chuck Grassley (IA), Mike Crapo (ID), Pat Roberts (KS), Mike Enzi (WY), John Cornyn (TX), John Thune (SD), Richard Burr (NC), Johnny Isakson (GA), Rob Portman (OH), Patrick Toomey (PA), Dan Coats (IN), Dean Heller (NV) and Tim Scott (SC).

2. Administration

On Dec. 16, CMS released the final 2018 notice of benefit and payment parameters, a major regulation that sets policy for the health care law’s exchanges and other insurance programs.

The 465-page rule outlines changes to the ACA risk adjustment model, standardized plan benefits and special enrollment periods among other topics.

For more information, click here.

The Obama administration has decided to drop its controversial test of new ways of paying for often costly drugs in Medicare Part B. The proposal, aimed at reducing drug spending, spurred a heavy lobbying campaign against it, and sharp criticism from Congress.

The Part B drugs are administered by physicians and include costly medications for cancer and other diseases.

CMS Unveils New Quality Sites for Rehab Facilities, Long-Term Care Hospitals

On Dec. 14, CMS unveiled new Compare websites for both Inpatient Rehabilitation Facilities (IRFs) and Long-Term Care Hospitals. The new websites will allow the public to compare metrics for more than 1,100 rehab facilities and 420 long-term care hospitals across the country. Measures that will be reported on the websites relate to patient pressure ulcers and unplanned readmissions within 30 days of discharge.

For more information, click here.

The deadline to sign up for Obamacare coverage starting Jan. 1 has been extended for four days, until Dec. 19, amid high volume on the HealthCare.gov website and the call center. Nearly 1 million people have left contact information to hold a place in the signup line, HealthCare.gov CEO Kevin Counihan said.

On Dec. 14, the Obama finalized a rule on the Title X program that is designed to shield abortion providers against state defunding efforts. The regulation would ban grant recipients from prohibiting family-planning providers if the basis for those decisions is not related to their ability to administer services. The Title X program provides funding for a broad array of family planning services, including STD screening and treatment, but funding is not used to pay for abortions.

According to HHS, 13 states since 2011 have taken actions to restrict participation by family planning providers in Title X because they provide abortions. Planned Parenthood has often been the subject of defunding actions at the state level and in Congress.

However, abortion rights supporters acknowledged the final rule may be short-lived. Republican sources have already said the incoming Trump administration can quickly undo this rule. Republican lawmakers next year are also expected to act quickly to cut off Planned Parenthood’s federal funding.

On Dec. 15, the Centers for Medicare and Medicaid Services (CMS) announced the Medicare-Medicaid Accountable Care Organization (ACO) Model, a new initiative designed to improve the quality of care and lower costs for beneficiaries who are dually eligible for Medicare and Medicaid. Through the model, CMS intends to partner with interested states to offer ACOs the opportunity to take on accountability for both Medicare and Medicaid costs and quality for their beneficiaries.

In current Medicare ACO initiatives, beneficiaries who are Medicare-Medicaid enrollees may be attributed to ACOs. However, Medicare ACOs often do not have financial accountability for the Medicaid expenditures for those beneficiaries. The Medicare-Medicaid ACO Model will allow Medicare Shared Savings Program ACOs to take on accountability for the quality of care and both Medicare and Medicaid costs for Medicare-Medicaid enrollees.

CMS is accepting letters of intent from states that wish to work with CMS to design certain state-specific elements of the model. The model is open to all states and the District of Columbia that have a sufficient number of Medicare-Medicaid enrollees in fee-for-service Medicare and Medicaid. CMS will enter into participation agreements with up to six states with preference given to states with low Medicare ACO saturation. Once a state is approved to participate in the model, a request for application will be released to ACOs and health care providers in that state.

For more information on the Medicare-Medicaid ACO Model, including a fact sheet, click here.

On Dec. 9, CMS received approval for the OASIS-C2 form, developed to accommodate new data being collected for the Home Health Quality Reporting Program in support of the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act). Effective Jan. 1, 2017, HHA providers and vendors will begin using the OASIS-C2 in submitting assessments.

The guidance manual for OASIS-C2 is available here.

On Dec. 13, CMS released its Person and Family Engagement Strategy, one of the six goals outlined in the CMS Quality Strategy . The goal of the PFE Strategy is to create a new health care system that proactively engages people and caregivers in the definition, design and delivery of their care.

The PFE Strategy will serve as a guide for the implementation of person and family engagement principles and strategies throughout CMS programs. This strategy will expand the awareness and practice of person and family engagement by providing the following goals and objectives:

  • Goal 1 : Actively encourage person and family engagement along the continuum of care within the broader context of health and well-being in the communities in which people live.
  • Goal 2: Promote tools and strategies that reflect person and/or family values and preferences and enable them to actively engage in directing and self-managing their care.
  • Goal 3: Create an environment where persons and their families work in partnership with their health care providers to develop their health and wellness goals informed by sound evidence and aligned with their values and preferences.
  • Goal 4: Develop meaningful measures and tools aimed at improving the experience and outcomes of care for persons, caregivers and families. Also, identify person and family engagement best practices and techniques in the field that are ready for widespread scaling and national integration.

For more information, click here .

On Dec. 13, CMS released an interim final rule requiring new disclosures for Medicare dialysis facilities that help patients pay their premiums either directly or through a nonprofit charity or other third-party payer. CMS also announced it will pilot its pre-enrollment verification system for special enrollment periods in all federally facilitated marketplace (FFM) states and counties starting in June 2017.

Fifty percent of new applicants will be randomly selected for the pilot, which will include all special enrollment categories. Applicants in the pilot—which was first announced in September—will still be able to apply and select a plan, but their enrollment will be pended until the consumer submits documentation proving eligibility. Applicants will have 30 days to provide the information. Once the document has been provided, the FFM will send the application to the issuer, and coverage can begin once payment is received. CMS will train navigators and other enrollment assisters as well as agents and brokers on how to help consumers, and will add instructions to HealthCare.gov.

CMS plans to evaluate the impact of pre-enrollment verification on the risk pool using data on 2017 claims that will become available in the spring of 2018, and will also look at how the pilot affects enrollment and other metrics on an ongoing basis.

On Dec. 9, CMS posted the final Medicare Outpatient Observation Notice after withdrawing a notice the agency said was posted prematurely earlier in the week.

The final notice, required under the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, is a standard form that hospitals and critical access hospitals must provide to beneficiaries who receive observation services to let them know they are receiving outpatient care and have not been admitted to the hospital. The final notice also lays out the potential consequences for beneficiaries of receiving outpatient care.

Hospitals have 90 days to implement the new notice and must provide it to beneficiaries under observation starting March 8.

3. Courts

The Justice Department has charged two former senior executives with Heritage Pharmaceuticals for their roles in alleged conspiracies to fix prices for certain generic drugs. Former company CEO Jeffrey Glaze and Jason Malek, the company’s former president, were also accused of rigging bids and allocating customers for an antibiotic and a diabetes drug. The company ran its antibiotic scheme from as early as April 2013 until at least December 2015 and fixed prices for the diabetes drug between April 2014 and December 2015, DOJ said.

Nearly two dozen state attorneys general have named New Jersey-based Heritage Pharmaceuticals and other companies in a lawsuit accusing them of conspiring to increase generic drug prices.

The officials, including New York Attorney General Eric Schneiderman, accuse the companies of committing significant harm to the nation’s health care system by artificially increasing the price for the antibiotic doxycycline hyclate and glyburide, an oral diabetes medication, according to a complaint filed under seal in U.S. District Court in Connecticut.

The suit also accuses Aurobindo Pharma USA, Inc.; Citron Pharma, LLC; Mayne Pharma (USA), Inc.; Mylan Pharmaceuticals, Inc.; and Teva Pharmaceuticals USA, Inc., of colluding with their competitors at “industry dinners,” “girls’ nights out,” lunches and parties, and through numerous and frequent telephone calls, emails and text messages.

Fearing that prosecutors might one day catch on, many of these communications were done in person or via text to avoid creating a record. Heritage is accused of being the ringleader, according to the court filings.

The U.S Justice Department on Wednesday charged two Heritage executives with conspiring to fix prices on generic drugs. Jeffrey Glazer, a former chief executive officer of Heritage, and Jason Malek, an ex-president, are preparing to plead guilty and cooperate with investigators.

The criminal charges and the civil suit stem from a sweeping two-year investigation into the pricing of generic drugs. The investigation began in Connecticut. Aside from Schneiderman, the attorneys general participating in the suit are from Connecticut, Delaware, Florida, Hawaii, Idaho, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Nevada, North Dakota, Ohio, Pennsylvania, Virginia and Washington.

Read the complaint here.

Supreme Court Declines to Hear Apotex v. Amgen

On Dec. 12, the U.S. Supreme Court declined to hear a challenge to an appeals court ruling that effectively gave brand drugmakers an additional six months of marketing protection from inexpensive biosimilars.

Apotex had asked the high court to reverse the Federal Circuit’s July ruling that the company had to wait until it received FDA approval of its biosimilar to Amgen’s Neulasta before it could give Amgen the required 180 days’ notice of its intent to launch the copycat drug. Apotex had argued it could file that notice earlier so that it could launch the drug immediately following FDA’s approval.

However, the Supreme Court could still weigh in on the issue, which will affect how quickly cheaper versions of some of the most expensive drugs could reach patients. The Supreme Court must still decide whether to take up Sandoz v. Amgen. In that case, Sandoz asked the Supreme Court to overturn an identical decision from the Federal Circuit.

The solicitor general weighed in and said the high court should take up Sandoz v. Amgen and overturn the Federal Circuit’s decision that the 180-day notice must come after FDA approves the biosimilar.

Amgen also asked the Supreme Court to reverse the appeals court’s decision that biosimilar makers do not have to engage in a patent-sharing process with branded biologic makers. The solicitor general said that part of the Sandoz v. Amgen ruling should stand.

4. State Activities

Arkansas: CMS Approves Governor’s Proposed Medicaid Expansion Changes

On Dec. 7, Arkansas Gov. Asa Hutchinson said that the Obama administration has approved most of his proposed changes to the state’s Medicaid expansion program. Though CMS did not grant all of the governor’s more conservative requests for the program, it will allow the state to charge premiums and require certain recipients to look for a job. CMS did not approve Hutchinson’s proposal to provide assistance to all businesses that provide health insurance to their workers.

California’s Obamacare exchange is pushing back the deadline to enroll in coverage starting in the new year, citing an increase in demand. The new signup deadline for Jan. 1 coverage is midnight on Dec. 17, two days later than the original Dec. 15 deadline. State exchange officials said more than 25,000 new enrollees chose plans on Monday and Tuesday, nearly double the 13,000 people who selected plans during the same dates last year.

More than 153,000 new customers have selected Obamacare plans in California since enrollment began six weeks ago. Those figures are not included in CMS enrollment updates for HealthCare.gov states. In the 39 states using the federal enrollment website, more than 4 million people selected plans between Nov. 1 and Dec. 10. Most states set Dec. 15 as the deadline to enroll in coverage starting Jan. 1, although some did not. For instance, the deadline in Massachusetts is Dec. 23.

In other news, California alone accounts for nearly a third of the adults who could lose Medicaid coverage if the ACA is repealed. The Kaiser Family Foundation (KFF) analysis, which relies on Medicaid enrollment by state in 2015, shows nearly 3.5 million California adults have become newly insured through the expansion effort. That is a significant portion of the statewide Medi-Cal population of more than 13 million, and far more than any other state.

California: Sen. Hernandez Reintroduces Drug Pricing Legislation

California Sen. Ed Hernandez, who chairs the Senate Committee on Health, recharged his fight against rising drug prices by reintroducing legislation for the 2017-18 session that would require pharmaceutical companies to provide advance notification of their price increases. The Democrat pulled his previous effort, S.B. 1010, from consideration in August after amendments had watered down the legislation too much.

The details of the new version, S.B. 17, have not been hammered out, but the previous version would have required drugmakers to warn health insurers and state programs in writing if they planned to raise drug prices by 10 percent or more, or if a drug was going to cost more than $10,000 for an annual course of treatment.

Louisiana: State Prisons to Enroll Ex-Inmates in Medicaid Beginning Jan. 1

In January, as part of the state’s Medicaid expansion program, seven state-owned prisons will begin automatically enrolling prisoners in Medicaid on the day they are released. Implementation of the enrollment program will start roughly six months after expansion took effect under Democratic Gov. John Bel Edwards. Louisiana is among a handful of states—including Ohio and Massachusetts—that have inmate Medicaid enrollment programs in place. The Louisiana Department of Health said it will also identify high-need inmates and assign them case managers to make sure they receive sufficient medical or behavioral care.

Oregon: Gov. Brown Trying to Secure Medicaid Waiver Before Trump Takes Office

Oregon Gov. Kate Brown is attempting to get CMS’s approval for a Medicaid waiver that would extend the state’s coordinated care organizations program before Trump takes office. The waiver would extend Oregon’s system for coordinated care organizations, which is scheduled to sunset next year.

Vermont: Vermont Receives Start-up Funding for All-Payer Waiver

On Dec. 15, CMS issued a notice officially outlining the amount of start-up Medicare funding Vermont will receive for its all-payer waiver, which was approved in October and will begin in January. The state will get $9.5 million to help achieve the health outcomes and financial goals under the model. The waiver aims to contain health care cost growth across Medicare, Medicaid and private insurance. Vermont will seek to limit annual cost growth to 3.5 percent per capita.

To read the CMS notice, click here.

Washington: Letter Urges Republican Lawmakers Against Dismantling Obamacare

Washington state Gov. Jay Inslee and insurance commissioner Mike Kreidler are urging Republican lawmakers not to pursue efforts to dismantle Obamacare or make cuts to Medicaid and Medicare. In a letter sent to House Majority Leader Kevin McCarthy, Inslee and Kreidler say that “it would be a moral outrage to repeal the health care policies that are so beneficial to millions of Washingtonians without providing an alternative system to make sure all our families continue to have access to affordable care.” McCarthy recently requested feedback from state officials on Congress’s Obamacare repeal efforts.

5. Regulations Open for Comment

On Nov. 3, CMS announced a proposed rule to update Medicare fire protection guidelines for certain dialysis facilities to ensure that patients are protected from fire while receiving treatment in those facilities.

The new proposed guidelines apply to all dialysis facilities that do not provide one or more exits at grade level from the treatment area level. CMS previously updated the requirements to include dialysis facilities located adjacent to industrial high-hazard occupancies; however, as dialysis facilities are not permitted to be located in such areas, the requirement specific to such geographically located facilities will be removed.

The rule adopts, for certain dialysis facilities, updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the Life Safety Code (LSC), as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code in order to bring CMS’s requirements more up to date with current fire safety standards. The LSC is a compilation of fire safety requirements for new and existing buildings, and is updated every three years.

The proposed rule addresses construction, protection and operational features of dialysis facilities to provide safety for Medicare beneficiaries from fire and smoke. Some of the main requirements laid out in the rule include:

  • Doors to hazardous areas must be self-closing or must close automatically.
  • Alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.
  • A fire watch or building evacuation is required if the sprinkler system is out of service for more than 10 hours.

Currently, CMS is using the 2000 edition of the LSC to survey dialysis facilities for health and safety compliance. With this proposed rule, CMS is adopting provisions of the 2012 edition of the LSC and provisions of the 2012 edition of the Health Care Facilities Code, to bring CMS’s requirements more up to date, and align dialysis facility fire safety requirements with the codes CMS uses to survey other healthcare facilities.

On Nov. 7, CMS issued a proposed notice announcing changes that would be made to the Medicaid National Drug Rebate Agreement (NDRA) for use by the Secretary of the Department of Health and Human Services and manufacturers under the Medicaid Drug Rebate Program. The NDRA is being updated to incorporate legislative and regulatory changes that have occurred since the agreement was published in February 1991, as well as to make editorial and structural revisions, such as references to the updated Office of Management and Budget (OMB)-approved data collection forms and electronic data reporting. There is a 90-day comment period for this proposed notice that will end on Feb. 7, 2017.

For more information, click here.

On Nov. 4, CMS announced that public comments are due Nov. 17 on a cross-setting post-acute care measure under the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) to further develop and refine the percentage of residents or patients with pressure ulcers that are new or worsened and language modifications being explored with the term “Pressure Injury.” CMS seeks feedback on potential updates to measure specifications and items used to calculate the quality measure. Visit the Public Comment webpage for more information.

CMS Issues Interim Final Rule to Delay Inclusion of U.S. Territories in Definitions of States and United States

CMS published the Covered Outpatient Drug Final Rule with Comment Period in the Federal Register on Feb. 1, 2016. As part of that final rule with comment, CMS amended the regulatory definitions of “States” and “United States” to include the U.S. territories (American Samoa, the Northern Mariana Islands, Guam, the Commonwealth of Puerto Rico and the U.S. Virgin Islands) beginning April 1, 2017. However, the agency said those territories could not be ready to implement the program by this date.

Therefore, CMS issued an Interim Final Rule with comment period that delays the inclusion of the territories in the definitions of “States” and “United States” from April 1, 2017, until April 1, 2020, which is effective on Nov. 15, 2016. There is a 60-day comment period that will end on Jan. 17, 2017.

For more information visit theCovered Outpatient Drugs Policy page on Medicaid.gov.

CMS has issued a new proposed rule detailing regulations for pass-through payments to providers from Medicaid managed care plans. The guidance builds on the Medicaid managed care rule finalized by the Obama administration in May.

Read the proposed rule here. It is scheduled to be published in the Federal Register on Nov. 22.

6. Reports

The Congressional Budget Office (CBO) recently laid out several ACA-related policy changes in its new volume of deficit reduction options. The policy that would save the most, or more than $1.2 trillion from 2017 through 2026, is a repeal of all the ACA coverage provisions, which includes the Medicaid expansion, ACA subsidies, employer and individual mandate, Cadillac and other taxes, and market regulations such as coverage of pre-existing conditions, benefits and age rating.

CBO projects the repeal would increase the number of uninsured Americans by about 23 million over the same time frame. CBO separately looked at the impact of repealing the individual mandate, and found it would reduce the federal deficit by $416 billion through 2026. Eliminating the mandate would also increase the number of uninsured Americans by about 17 million, and would increase premiums in the individual market by about 20 percent.

CBO and the Joint Committee on Taxation also looked at what would happen if Congress stripped the 40 percent tax on high-cost plans, and instead implemented limits to the tax treatment of employer-sponsored coverage. The GOP’s Better Way plan as well as HHS Secretary-nominee Tom Price’s (R-GA) health reform proposal and other GOP plans all propose a similar policy, but will face strong opposition from employer and labor groups.

The Congressional Budget Office (CBO) outlined choices Republicans have to cap Medicaid spending and said the potential 10-year deficit reductions range from $370 billion to $680 billion, depending on the design of the policy.

CBO estimates that caps on spending per enrollee, with spending growth based on the Consumer Price Index for urban consumers plus 1 percent, would save $370 billion over a decade, while using block grants that peg inflation to the same growth rate would cut spending by $486 billion. If the government used block grants and limited spending increases to the CPI-U, the deficit reduction would equal $680 billion.

Republicans in Congress and the incoming administration say they want to make changes to Medicaid that reduce federal spending, but they have yet to work out the details. Some had expected House Republicans’ Medicaid task force to recommend legislative changes to Medicaid, but the task force chair recently said the group will not make recommendations. Seven states have stopped plans to expand Medicaid while Republicans work out program reforms.

Short of legislative changes to allow block grants or per-capita caps, the Trump administration could let states cut Medicaid eligibility and benefits or make trade-offs between exchange and Medicaid coverage.

CBO’s biannual report on options for reducing the deficit lists the main policy questions that Republicans would need to answer if they cap the federal share of Medicaid financing.

GAO Report Identifies Challenges for Small, Rural Practices in Value-Based Payment Models

Based on a review of literature and interviews with 38 stakeholders, GAO identified challenges faced by small and rural physician practices when participating in Medicare’s new payment models. These models, known as value-based payment models, are intended to reward health care providers for resource use and quality, rather than volume, of services. The challenges identified are in five key topic areas:

  1. Financial resources and risk management
  2. Health IT and data
  3. Population health management care delivery
  4. Quality and efficiency performance measurement and reporting
  5. Effects of model participation and managing compliance with requirements

For example, GAO found that some of these practices have small budgets, making it harder for them to invest in the training and technology they need to participate. GAO also found that not all of these practices have access to organizations that can help them share staff and IT systems.

For the full report, click here.

GAO Report Finds More Action Necessary on Prescription Drug Labels for Blind or Visually Impaired Individuals

Over 7 million Americans are blind or visually impaired and may have trouble reading the labels on prescription drug containers. In a new report on prescription drug labels, GAO found that some pharmacies can provide accessible labels in audible, braille and large print formats but dispense very few prescriptions with these labels. GAO also found that the National Council on Disability has conducted limited activities to inform pharmacies and the public about best practices for accessible prescription drug labeling. GAO recommended that NCD assign responsibility for conducting those activities, and evaluate its efforts to raise awareness of best practices.

For the full report, click here.

Each year, more than 12,000 newborns are diagnosed with conditions that can cause severe disability or death if not treated quickly. To screen for such conditions, health care providers collect blood samples from newborns and send them to labs for testing.

According to a new GAO report, states face barriers to timely screening—such as issues with sending samples to labs—that can delay treatment. Most states had not yet met their goal to screen 95 percent of blood samples within seven days of birth by 2017, although some have improved screening time. For example, one state expanded courier service so all rural hospitals can get their samples to the lab more quickly.

For the full report, click here.

GAO was asked to test marketplace enrollment and verification controls for applicants attempting to obtain coverage during a special enrollment period (SEP). A new report describes the results of GAO attempts to obtain subsidized qualified health-plan coverage during the 2016 SEP in the federal marketplace and two selected state-based marketplaces—California and the District of Columbia.

To perform the undercover testing of enrollment verification, GAO submitted 12 new fictitious applications for subsidized health-insurance coverage outside of the open enrollment period in 2016. GAO’s applications tested verifications related to a variety of SEP triggering events. The federal and state-based marketplaces approved health-insurance coverage and subsidies for 9 of 12 of GAO’s fictitious applications.

GAO did not make any recommendations to HHS. For the full report, click here.

If you have any questions, contact the following individuals at McGuireWoods Consulting:


Stephanie Kennan, Senior Vice President Charlie Iovino, Vice President Caroline Perrin, Research Assistant


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