The OIG’s 2015 Health Reform Oversight Plan: Health Insurance Marketplaces and Other ACA-Related Reforms

The OIG’s 2015 Health Reform Oversight Plan: Health Insurance Marketplaces and Other ACA-Related Reforms
Senior Director of Marketing

On February 24, 2015, the Office of Inspector General (OIG) released its Health Reform Oversight Plan for the fiscal year 2015, which describes their current and planned efforts to oversee the implementation and management of the Department of Health and Human Services’ (HHS’s) programs under the Affordable Care Act (ACA). This plan focuses primarily on the OIG’s oversight through audits and evaluations. 

This plan identifies the OIG’s four key strategic goals in overseeing ACA programs:

  1. Fighting fraud, waste and abuse
  2. Promoting value, safety and quality
  3. Securing the future
  4. Advancing excellence and innovation

Strategically aligned with these goals, the Oversight Plan highlights two key areas of focus for the OIG in 2015 and beyond: health insurance Marketplaces and other ACA-related reforms.

Health Insurance Marketplaces

Marketplaces and related programs will be a primary focus in this fiscal year’s oversight plan. Specifically, the OIG will focus on answering questions in four key areas:

  1. Payments: Are taxpayer funds being expended correctly for their intended purposes? The OIG will design future work to address vulnerabilities in payment systems and the appropriate use of Federal funds.
  2. Eligibility: Are the right people getting the right benefits? They will continue to review internal controls related to eligibility for enrolling in qualified health plans (QHPs) and for financial assistance programs in the Marketplaces.
  3. Management and Administration: Is the Department managing and administering Marketplace programs effectively and efficiently? They will design future work to address management and administration issues associated with Marketplace functionalities, which can cover the redetermination process for consumers enrolling in the federally facilitated Marketplace (FFM).
  4. Security: Is consumers’ personal information safe? The OIG is working closely with law enforcement partners in other agencies to monitor for reports of cybersecurity threats and consumer fraud incidents.

Health Reform in Other HHS Programs

Although the Marketplaces will receive substantial attention from the OIG, they will also conduct and develop oversight work addressing reforms in other programs. There are four key areas where the OIG plans to conduct ongoing and potential work:

  1. Medicaid Expansion and Services: The OIG will conduct work examining the accuracy of States’ eligibility determinations.
  2. Medicare Payment and Delivery Reform: They are continuing to develop oversight work on Medicare’s transition to value-based payment and coordinated delivery of care to address the spectrum of payment reform.
  3. Medicare and Medicaid Program Integrity: They are examining the implementation and effectiveness of provisions of Title VI of the ACA designed to strengthen transparency and program integrity in Medicare and Medicaid. This includes reviewing enhanced provider screening systems.
  4. Public Health Programs: The OIG is examining ACA reforms designed to improve public health, prevention, and wellness through oversight of grant programs such as the Community Health Centers Fund and the Prevention and Public Health Fund.

For more details about the OIG’s 2015 Oversight Plan, access the full document here.

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