DGS Health Law Blog : Denver Health Care Lawyers & Attorneys : Davis Graham & Stubbs Law Firm : HIPAA & Patient Privacy : Colorado, Rocky Mountain West

Colorado was one of five states selected to receive a Level 1 funding grant this week from the Department of Health and Human Services.  The Level One Exchange Establishment Grant is a one-year grant designed to help states develop their health insurance exchanges.  Colorado applied for and received a $43 million grant which will "support planning activities, including the initial acquisition of technology services to begin building the online shopping portal."  This is Colorado's second Level 1 grant; it first received an award of $17.9 million in February 2012. 

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All eyes turned to Vermont today as Governor Peter Schumlin signed into law a bill creating a board to oversee the planning and development of a state-sponsored insurance plan, Green Mountain Care.  With the stroke of a pen, Vermont  became the first state to move significantly toward a single-payer insurance system.  One hurdle standing in Vermont's way is the need to secure a waiver from PPACA, which won't be available until 2017 under current law.  Although there appears to be support for moving that deadline up to 2014, it remains to be seen how strong that support really is.  

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The new CMS Innovation Center, in cooperation with the Federal Coordinated Health Care Office, announced recently that it is partnering with fifteen states across the U.S. in an effort to design new approaches to better coordinate care for dual eligibile patients (i.e., those patients eligible for both Medicare and Medicaid). 

Colorado and fourteen other states were each awarded up to $1 million to develop a model describing how the state would structure a patient-centered approach to coordinate care across primary, acute, behavioral health, and long-term supports and services for dual eligible individuals.  This initiative is funded by the Affordable Care Act.

CMS has explained that the goal of this demonstration program is to identify delivery system and payment coordination models that eliminate duplication of services, expand access to care, and lower costs for dual eligibles.   After federal review of the proposals, CMS will work with states to implement the plans that hold the most promise, eventually testing them and replicating them in other states.

For more information on this new initiative, see the CMS Innovation Center's announcement or CMS's website and press release.

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Health care fraud and abuse enforcement is always on our minds and our clients' minds, but yesterday HHS and DOJ gave health care providers even more to consider when evaluating their own fraud and abuse compliance efforts.

HHS and DOJ announced the highest annual recovery amount ever from health care providers as a result of the federal government's fraud and abuse enforcement efforts.  According to the annual Health Care Fraud and Abuse Control Program ("HCFAC") report released yesterday, the government’s health care fraud prevention and enforcement efforts recovered a staggering $4 billion from health care providers in fiscal year 2010.

This year's $4 billion recovery amount is up 50% from 2009.  To further put this $4 billion into context,  the HCFAC has returned $18 billion total to the Medicare Trust Fund since its inception in 1997.  This increased recovery is due, at least in part, to the recently employed enforcement teams such as the Health Care Fraud Prevention & Enforcement Action Team ("HEAT") and the Medicare Fraud Strike Force.  In addition to these criminal enforcement recoveries, the government also obtained more than $2.5 billion in civil health care matters brought under the False Claims Act, which is the largest in the history of the DOJ. 

HHS also announced yesterday new rules authorized by PPACA (or the Affordable Care Act) that will further intensify the government's efforts to fight fraud, waste and abuse in Medicare and Medicaid.  Not only does PPACA provide an additional $350 million for HCFAC activities, but the rules include new provider screening and enfocement measures and gives the government the authority to suspend payments to providers when credible allegations of fraud are being investigated.  These provisions--particularly the suspension of payment during investigations--are likely to have a significant impact on providers in the coming years.  These regulations take effect March 25, 2011.

Although these recovery amounts seem high compared to previous years, health care providers should expect that recoveries may increase even further in coming years with the government's sharpened focus on health care fraud and abuse.

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Today marks six months from the date that the Patient Protection and Affordable Care Act was enacted.  Several key provisions of the law become effective today, September 23, 2010, including:

• Expansion of coverage for dependents up to 26 years old. 
• Elimination of annual or lifetime dollar limits to the amount of money spent on health care services.
• Prohibition of denials of coverage to children under 19 years old for preexisting conditions.
• Coverage for all preventative services with no co-pays.
• Free preventative care (for all new plans).

These changes take effect immediately for any new policies bought after today.  For those with existing policies, however, the changes will take effect either during the next open enrollment period (for employer-based plans) or at the time a policy is renewed (for individually-purchased plans).  

To read more about these changes, CNN has posted this article and the government's new health care reform website has posted this article.

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