Tuesday, July 31, 2012

Dependent Audit Case Studies, after PPACA

Client A is a small company in transportation and manufacturing.  Anticipating the changes required after 9/23, Client A modified its policy into a non-grandfathered plan with extended child eligibility to 26 at their 9/1/2010 plan renewal, in advance of the PPACA requirement.  At the time of verification, the company had been following the Age 26 rule for four months.  As a small company that had already implemented the health care reform changes, leadership expected to see low ineligible dependent numbers.  Instead, the Dependent Eligibility Verification found that 14.5% of dependents on the plan were ineligible.

Client B is a large retail chain with mostly white collar employees in a low-income tax bracket.  Its plan renewal was 2/1/11, and under its Ongoing Verification procedures, the company began verifying for the new health care reform categories in mid-January.  Client B implemented a grandfathered policy with an Adult Child Exclusion policy:  if an adult child was eligible for coverage under his or her own employer’s policy, that dependent was not eligible for the policy of Client B.  Open Enrollment numbers showed a 20% increase of enrollees to the policy, which fit with its expectations for the 2011 year. 

The big surprise, though, was the upswing of ineligibles:  during the original verification, between October 2009 and January 2010, the ContinuousHealth Dependent Eligibility Verification Audit found that 1,851, or 16.56%, of Client B’s 11,175 dependents enrolled were ineligible; during the first four months following the implementation of PPACA regulations, the ContinuousHealth ongoing dependent eligibility verification audit found 549, or 30.57%, of the 1,796 newly enrolled dependents to be ineligible for the new policy. This number was nearly double the findings of the original project, when the eligibility criteria were more stringent. Throughout the whole 2011 year, ineligible numbers came down, but were still considerably higher than the findings of the initial project, as between January and December 2011, ContinuousHealth identified that 26.84% of dependents did not meet the requirements to verify their eligibility for the plan. With the change in plan requirements under PPACA, Client B regularly found an increased rate of ineligibility by between ten and fourteen percent.

Client C is a major automotive manufacturing company with a non-grandfathered plan and a February plan renewal.  The company began verifying for new categories in mid-February.  Prior to health care reform provisions, the Dependent Eligibility Verification Audit identified 10.55% of enrolled dependents as ineligible. 

After enacting the Age 26 requirement and removing a residential requirement for stepchildren, the Ongoing Dependent Eligibility Verification found that 27.91% of new enrollees were ineligible during the first four months of PPACA.  For the 2011 year, Continuoushealth identified 24.1% of dependents on the plan were ineligible for coverage, a slight drop from the first few months.  Overall, Client C has found an increase of more than double the rate of ineligibles since PPACA.

Client D is a large hospital management system with 15 localized hospitals.  The management system did a Dependent Eligibility Verification Audit in 2010, prior to implementing health care reform at their July 1, 2011 plan renewal, with 13 of its 15 hospitals. The two hospitals who did not participate initially were both located in Massachusetts and were excluded because they were covered under “RomneyCare,” a set of provisions that representatives of President Obama have cited as a model for PPACA[1] and which have been called an “ObamaCare preview.”[2]

After the leadership team reviewed the results from the initial verification, the two hospitals in Massachusetts decided to undergo a ContinuousHealth Dependent Eligibility Verification Audit as well. The results were comparable with their non-Massachusetts counterparts:  the original verification found 10.1% ineligibles for hospitals that were not yet subject to PPACA; one Massachusetts hospital discovered that 6.34% of dependents were ineligible and the other found 9.64% of dependents were ineligible under the current plan guidelines.[3]

After the first plan renewal for the entire system under PPACA (7/1/2011), leadership requested that all hospitals undergo another dependent eligibility review.  The hospitals all had similar plan eligibility, all non-grandfathered with no spousal exclusions or surcharges. During that post-PPACA review in fall of 2011, ContinuousHealth identified 21.01% of the active dependents on the plan were unable to satisfy eligibility requirements. Specifically, the two hospitals in Massachusetts each found 10.29% and 16.19% ineligible during the second review. All hospitals saw an increase in ineligible dependents. The post-PPACA verification savings for Client D totaled more than $5 million in claims cost reduction. 

Client E is a national restaurant chain with hourly and salaried employees throughout the US. At the time of review, Client E had been following PPACA guidelines for 12 months. The Human Resources team systematically requested documentation for any new enrollees, but the client had not done full documentation verification. ContinuousHealth identified 6.08% of the plan participants were ineligible for coverage under the non-grandfathered plan guidelines. Ineligible dependents were primarily over the age of 18 years old and may have been added on the plan as “spouses” or “adult children,” though they were, in fact, unable to verify their eligibility as such.

 






Client A
Client B
Client C
Client D
Client E
Industry
Transportation / Manufacturing
National Retail Chain
Automotive Manufacturing
Hospital Management System - 15 hospitals
National Restaurant Chain
# Dependents
350
11,000+
3,500
17,000+
1,300
Grandfathered or Non-Grandfathered
Non-grandfathered
Grandfathered: 
Adult Children eligible for own employers’ plans were ineligible
Non-grandfathered
Non-Grandfathered;
2 Hospitals under “RomneyCare”
Non-Grandfathered
First Plan Renewal
9/1/2011, but implemented on 9/1/2010;
Age 26 compliant for 4 months at verification start
2/1/2011;
started verifying for HCR in mid-January
2/2011;
started verifying for HCR in mid-February
7/1/2011
1/1/2011
Results
14.5% of dependents were ineligible, far higher than leadership expected
·  20% increase in Open Enrollment numbers

·  Original project in 2009-2010 found 16.56% of 11,175 dependents were ineligible

·  First 4 months of PPACA showed that 30.57% of the 1,796 newly enrolled were ineligible

·  2011 showed that 26.84% of the 2,724 newly enrolled were ineligible
·  Original DEVA found 10.55% of enrolled were ineligible

·  Post-HCR DEVA found 27.91% of new enrollees were ineligible

·  2011 showed 24.1% of the 1,229 newly enrolled were ineligible

·  Initial project:  10.1% ineligibles

·  2 “Romneycare” hospitals excluded from initial verification did a DEVA after seeing other 13 hospitals’ results

·  Results were comparable: RomneyCare project:  6.34% ineligibles in one and 9.64% in the other

·  Post-PPACA found 21.01% ineligible overall
·  Identified 6.08% of active dependents were ineligible
Financial Exposure Reduction
Over $184,960
·  Original project:  $4,995,000
·  First 4 months of PPACA: $1,482,300
·  2011 verification: $1,462,000 (with a decrease in claims cost)
·  Original project:  $1,114,345

·  First 4 months of PPACA: $1,500,442

·  2011: $929,144
Total savings:  $4,165,246
Total savings:  $262,833


[1] Carol E. Lee, “White House Again Jabs Romney on Health Law,” Washington Wire, Wall Street Journal, http://blogs.wsj.com/washwire/2011/05/13/white-house-again-jabs-romney-on-health-law, (May 17, 2011).
[2] “National Health Preview:  RomneyCare’s bad outcomes keep coming,” Wall Street Journal, http://online.wsj.com/article/SB10001424052748703864204576313370527615288.html?KEYWORDS=national+health+preview+romneycare, (May 10, 2011).
[3] The hospitals from the original verification were also not doing document checks, while the two Massachusetts hospitals believed their employee document records were up to date, checking student status as well as IRS dependency, per their SPD.

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