FY 2017 Annual Performance Plan and Report

Topics on this page: Goal 1. Objective A | Table of Related Performance Measures | Analysis of Results | Plans for the Future | Objective Progress Update Summary

Goal 1. Objective A: Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured

Before the Affordable Care Act, millions of Americans lacked access to affordable health insurance. Many who did have health insurance had gaps in coverage, such as exclusions for pre-existing conditions, or they were one step away from losing coverage because of a change in employment. Individuals with health insurance faced increasingly high premiums and medical costs that drove some to bankruptcy or forced choices between maintaining health insurance coverage and paying for other household essentials.

HHS has been identified as the lead federal agency responsible for implementing the Affordable Care Act, which contains many new health insurance market reforms and programs to address these and other issues. The Affordable Care Act is making comprehensive health coverage available to millions of Americans who previously lacked access to or could not afford health insurance. As a result, about 17.6 million previously uninsured Americans have gained health coverage since the enactment of the Affordable Care Act. In part due to the affordable coverage available through the Marketplace, the uninsured rate among nonelderly, civilian, non-institutionalized adults has declined from 18.2 percent in 2010 to 13.3 percent in 2014 (see measure PHI7 below). This huge increase in coverage comes along with other significant improvements and policy developments by CMS, including requirements for comprehensive essential health benefits, preventive services with no cost-sharing, and guaranteed ability to obtain coverage regardless of pre-existing conditions as well as the expansion of Medicaid.

Starting in 2010 and continuing in 2016, HHS implemented new regulations aimed at increasing consumer protections and at creating a more competitive insurance market to both lower cost and improve quality. These protections and increased oversight of the insurance industry help ensure that consumers are receiving value for their premium dollars; this oversight will also make the healthcare system more responsive to the needs of patients, providers, and other stakeholders.

Within HHS, divisions such as ACL, AHRQ, CDC, CMS, IHS, OASH, ONC, and SAMHSA work to implement the reforms prescribed in the law to make affordable coverage more accessible. The Office of the Secretary led this Objective’s assessment as a part of the Strategic Review.

Objective 1. A Table of Related Performance Measures

Track the Number of Individuals who have Confirmed Enrollment through the Health Insurance Marketplaces (Lead Agency - CMS; Measure ID - PHI5)

Percentage of the Nonelderly United States Population Who are Uninsured (Civilian, Noninstitutionalized) (Lead Agency - CMS; Measure ID - PHI7)

Improve availability and accessibility of health insurance coverage by increasing enrollment of eligible children in Medicaid and CHIP (Lead Agency - CMS; Measure ID - CHIP 3.3)

Maintain or exceed percent of beneficiaries in Medicare fee-for-service (MFFS) who report access to care (Lead Agency - CMS; Measure ID - MCR1.1a)

Maintain or exceed percent of beneficiaries in Medicare Advantage (MA) who report access to care (Lead Agency - CMS; Measure ID - MCR1.1b)

Reduce the average out-of-pocket share of prescription drug costs while in the Medicare Part D Prescription Drug Benefit coverage gap for non-Low Income Subsidy (LIS) Medicare beneficiaries who reach the gap and have no supplemental coverage in the gap (Lead Agency - CMS; Measure ID - MCR23)

Maintain the number of months to produce the Insurance Component tables following data collection (MEPS-IC) (Lead Agency - AHRQ; Measure ID - 1.3.16)

Increase the percentage of enrolled homeless persons in the Projects for Assistance in Transition from Homelessness (PATH) program who receive community mental health services (Lead Agency - SAMHSA; Measure ID - 3.4.15)

Analysis of Results

The Heath Insurance Marketplaces are designed to make buying health coverage easier and more affordable. Starting in 2014, Marketplaces brought new transparency to the market and allow individuals to compare health plans, get answers to questions, find out if they are eligible for premium tax credits to reduce the cost of their monthly premiums, and enroll in a health plan that meets their needs. CMS is reporting a new measure tracking the number of qualified individuals who have confirmed enrollment through the Marketplaces. Consumers can enroll in a Marketplace operated by the federal government or by a state. The target enrollment number reflects the total enrollment across all states. Baseline data for Calendar Year (CY) 2014 for the first year of enrollment was 6,337,860 at the end of December. CMS set an ambitious CY 2015 target before the open enrollment period that began on November 15, 2014 (9 million) and set a CY 2016 target (10 million) before the open enrollment period that began on November 1, 2015.

HHS is securing and extending health insurance to the previously uninsured by implementing provisions created by the Affordable Care Act of 2010, such as working with States to set up Health Insurance Marketplaces, expanding Medicaid coverage to low-income Americans, and prohibiting insurance companies from dropping people when they get sick. Through this coordinated effort, partners have made significant progress in a short amount of time toward extending affordable coverage to the uninsured. According to NHIS data, the affordable coverage available through Medicaid expansion and Marketplace coverage contributed to a six percentage point drop in the uninsured rate between 2013, the year of the first Open Enrollment Period in October 2013, and the second quarter of 2015⁶. CMS is providing a new contextual indicator in this report that tracks the percentage of the United States civilian nonelderly noninstitutionalized population who are uninsured. The substantial increase in coverage comes along with other significant improvements and policy developments including requirements for comprehensive essential health benefits, preventive services with no cost-sharing, and guaranteed ability to obtain coverage regardless of pre-existing conditions as well as the expansion of Medicaid.

CMS is tracking progress toward improving the availability and accessibility of health insurance coverage by increasing enrollment of eligible children in CHIP and Medicaid. States submit quarterly and annual statistical forms, which report the number of children under age 19 who are enrolled in Medicaid, separate CHIP programs, and Medicaid expansion CHIP programs. The most recent combined enrollment figure was reported for 2014, when 43,689,824 children were enrolled in Medicaid and CHIP, falling short of the 2014 target of 46,617,385 children. The paper attached to the 2014 children’s enrollment report on Medicaid.gov is helpful in explaining the decrease. It is available here: http://www.medicaid.gov/chip/downloads/fy-2014-childrens-enrollment-report.pdf . The FY 2016 target has been reduced to reflect this updated data.

CMS has monitored fee for service and Medicare Advantage access to care and prescription drugs as measures of beneficiary satisfaction since the enactment of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. CMS met or exceeded FY 2015 targets reflecting beneficiary experience in FFS and MA access to care.

The Affordable Care Act also included changes to Medicare to enhance the affordability of prescription drugs. Through the Coverage Gap Discount Program, CMS seeks to reduce the costs Medicare Part D enrollees are required to pay for their prescriptions once they reach the coverage gap (commonly known as the “donut hole”). The program will accomplish these reductions through significant manufacturer discounts and increased Medicare coverage according to a predetermined scale for FY 2011 through 2020. In FY 2013, CMS exceeded its target for reductions.

The Medical Expenditure Panel Survey (MEPS)-Insurance Component (IC) provides annual national and state estimates of aggregate spending on employer-sponsored health insurance for the National Health Expenditure Accounts (NHEA) that are maintained by CMS and for the gross domestic product produced by the Bureau of Economic Analysis. In support of the Affordable Care Act, MEPS-IC state-level premium estimates are the basis for determining the average limits for the federal tax credit available to small businesses that provide health insurance to their employees. In FY 2010, a baseline of 6 months was established to make data available for use after data collection. Since baseline determination, AHRQ has been successful in maintaining the 6-month target.

SAMHSA recognizes that some populations have different needs for behavioral health services and is concerned about the needs of those with serious mental illness and/or co-occurring substance use disorder who experience homelessness or are at risk of homelessness. Many people experiencing homelessness also have a mental health issue(s) and/or substance use disorder(s). SAMHSA has committed to increase the percentage of homeless people served through its programs who receive behavioral health services. These include substance abuse and alcohol counseling, group supports, and treatments to reduce anxiety. In FY 2014, 64 percent of homeless enrolled in the Projects to Assist in the Transition from Homelessness (PATH) received mental health services, exceeding the target.

Plans for the Future

Through a multitude of communications and outreach efforts aimed at consumers, the CMS Office of Communications provides the information needed to make informed decisions about obtaining affordable coverage through the Health Insurance Marketplace. CMS plans to undertake a number of analysis and enhancement initiatives over the coming year to improve the effectiveness of communications and outreach. Plans include building a model to measure effectiveness of outreach on enrollment to inform future efforts, conducting consumer research to improve the consumer experience on Healthcare.gov, and documenting lessons learned.

CMS will continue working with states toward full compliance with the provisions of the Affordable Care Act and implementing regulations. This will include completion of systems development; implementation of fully compliant application, verification, and renewal policies and practices; and improved coordination with Marketplaces to achieve the vision of coverage of all eligible beneficiaries.

CMS will continue to aim outreach efforts to inform parents that they can enroll children in Medicaid and CHIP at any time of the year; CMS recently received an additional $40 million through the Medicare Access and CHIP Reauthorization Act to fund general outreach and enrollment grants, outreach grants that focus on American Indian and Alaska Native children, and the National Enrollment Campaign in FY 2016 and FY 2017.

In addition, CMS is working closely with States to implement Affordable Care Act provisions related to eligibility, enrollment, benefits, and cost sharing in Medicaid and CHIP.

CMS will continue to monitor beneficiary satisfaction with access to care for Medicare Fee for Service and Medicare Advantage using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. CMS will also analyze Medicare Advantage data at the plan, enrollee subgroup, and geographic levels to assist plans in developing interventions that are both actionable and targeted to maintain or improve performance on measures.

The Affordable Care Act requires that the Medicare Part D Prescription Drug Benefit coverage gap be closed completely by 2020 and CMS is working to reduce out-of-pocket costs for Medicare coverage for prescription drugs. Prior to the passage of the Affordable Care Act, a Medicare beneficiary was responsible for paying 100 percent of the prescription costs between the initial coverage limit and the catastrophic limit. CMS will aim to continue to reduce the coverage gap, using a combination of manufacturers’ discounts and enhanced Medicare benefits.

SAMHSA’s PATH program identifies and connects those experiencing chronic homelessness to primary medical and behavioral health services and housing. Many of those served suffer from serious mental illness. The services provided by the PATH program fill gaps in existing community resources and play a crucial role in communities’ strategic plans to end homelessness. For example, the need for standardized definitions is addressed through the PATH's Administrative Workgroup. PATH helps recipients address issues relating to retention, staff shortages, and funding at the local level as well.

FY 2014 Strategic Review Objective Progress Update Summary

Please note that this section summarizes the result of the FY 2014 HHS Strategic Review process, limiting the scope of content to that available prior to spring of 2015. Due to this constraint, the following may not be the most current information available.

Conclusions: Noteworthy Progress

Analysis: At the time of this review, HHS has made significant progress in a short amount of time toward our objective to extend affordable coverage to the uninsured. Since the enactment of the Affordable Care Act, nearly 18 million Americans have gained coverage. In part due to the affordable coverage available through Marketplace, the uninsured rate among nonelderly adults has declined by more than seven percentage points since the beginning of open enrollment in 2013.

This huge increase in coverage comes along with other significant improvements and policy developments including changes in application, verification, eligibility determination, coordination, and renewal of coverage, as well as expansion of Medicaid. In particular, the single, streamlined application for all insurance affordability programs has allowed consumers a more coordinated and consistent process for obtaining coverage.

Coverage has not only expanded to more people but it has also become more secure for beneficiaries, particularly those who have Medicaid and CHIP, due to the development of regulations that ensure these beneficiaries remain enrolled in coverage for as long as they are eligible. In addition, consumers have also gained broader access to coverage – at least one issuer offered coverage in each service area of the Marketplaces, ensuring that all consumers would have qualified health plan access.

HHS will continue to work to secure coverage for hard-to-reach populations. Now that a significant number of previously uninsured individuals have enrolled in health coverage programs, growing total enrollment further will require the Department to update its previous tactics, as the remaining uninsured are often hard-to-reach. Additional content and sample size increase was achieved for FYs 2014 and 2015 for the National Health Interview Survey, although not to the level that could have been achieved with the full Prevention and Public Health Fund request. The uncertainty of the availability of these funds impacts HHS’ ability to effectively plan for inclusion of the additional sample and content on the 2017 survey. HHS will also continue to explore ways to promote a full continuum of behavioral health services as part of Qualified Health Plans.

HHS is exploring opportunities to update and improve performance indicators for this strategic objective. HHS will work to improve the customer experience by examining Call Center staffing options and starting open enrollment with better data personalization in emails so that consumers have the most helpful information. HHS will work with state-based Marketplaces to move from current workarounds to improve the efficiency of their application, verification, and renewal of policies.

¹ The CY 2017 target will likely be set before the 2017 open enrollment period.

² The FY 2016 target, originally reported in the FY 2016 CJ as 48,667,385, was reduced to 45,271,662.

³ The FY 2013 results reflect enrollment at a "point in time", but States may subsequently revise their current and/or historical data at any time. For example, the FY 2013 enrollment total that was reported as of 3/2014 was 45,292,420, but as of 4/2015, enrollment was 42, 919,432, a difference of nearly 2.4 million children. This change is due primarily to improvements to data quality.

⁴, ⁵ After FY 2015, CMS will no longer set targets for this measure, but will report the annual result as a Contextual Indicator.

⁶ http://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly_estimates_2010_2015_Q12.pdf, Table 1.