This document discusses systems and reporting requirements under the Affordable Care Act. It covers key topics like systems for eligibility, enrollment, data collection, financial reporting, and electronic health records. It also addresses data validation, reporting requirements for enrollment, issuer, and financial data. Finally, it provides important dates for when systems must be in compliance and when various reporting deadlines take effect.

1. T HE A FFORDABLE C ARE A CT:
S YSTEMS & R EPORTING

2. O VERVIEW
• Systems
• Data Validation
• Program Integrity
• Financial Integrity
• Prevention of Fraud, Waste, and Abuse
• Program Transparency
• Reporting Requirements
• Key Dates
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3. SYSTEMS
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4. S YSTEMS
• Systems include both policies and procedures and
information technology systems (e.g., a database or a
website) put in place to accomplish a specific task or
requirement
• Systems should be established to support:
o Eligibility and Enrollment
o Data Collecting and Processing
o Financial Reporting
o Electronic Health Records (EHRs)
o Privacy and Security Standards
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5. S YSTEMS :
E LIGIBILITY AND E NROLLMENT
• Exchanges must have a system in place that will both
determine eligibility and enroll applicants into the chosen
QHP
• The system must:
o Have a web portal
o Be streamlined for simplicity
o Determine eligibility for government sponsored
healthcare/tax benefits
o Communicate with other systems, such as CMS and IRS
databases
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6. S YSTEMS :
D ATA C OLLECTING AND P ROCESSING
• ACA §4302 allows for data collection in order to determine
health care disparities and demographics
o Race and ethnicity, gender, primary language, and disability
status are the types of data collected
o Data is collected to ensure that minorities and underserved
communities have access to healthcare
• A work group consisting of HHS, OMB, and the Census
Bureau is helping states to develop standards for data
collection and processing
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7. S YSTEMS :
F INANCIAL R EPORTING
• In order to determine if an applicant is eligible for tax
credits, data must be provided to the Exchange
• Data submitted can include:
o Name, DOB, SSN
o Household size, Income
o Employer coverage
o EIN, # of employees, amounts paid for employee
• Exchanges will submit financial and demographic data
electronically
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8. S YSTEMS :
F INANCIAL R EPORTING FOR
TAX C REDITS
Small Business Health Care Tax Credit
o Employers report to IRS number of employees, employee
roster, average annual salary paid, and the amount paid for
employee health coverage
Health Insurance Premium Tax Credit
o Individuals need to report income information, family size,
and information on changes in circumstances
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9. S YSTEMS :
E LECTRONIC HEALTH R ECORDS
(EHR S )
• EHRs are digital health records that allow medical
providers (i.e., physicians and hospitals) to electronically
send and receive patient information to/from other
medical providers
• EHRs must follow the Health Insurance Portability and
Accountability Act (HIPAA), Protected Health Information
(PHI), and Personally Identifiable Information (PII)
standards for protecting patient’s medical information
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10. S YSTEMS :
P RIVACY AND S ECURITY S TANDARDS
• Exchanges are required to follow applicable HIPAA, PHI,
and PII security laws; and
• ACA §1104 administrative standards, which include :
o Standards and operating rules for EFT and remittance
advice,
o A unique identifier for health plans,
o A standard for claims attachments, and
o Requirements that health plans certify compliance with all
HIPAA standards and operating rules
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11. DATA VALIDATION
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12. D ATA VALIDATION :
A PPLICANT
Data validation for individual applicants by Exchange:
• Basic Information Verification  ensure all fields are complete
and data is valid
• Citizenship Verification  applicant’s citizenship status is
compared to Social Security Administration records or, in some
instances the Department of Homeland Security records
• Incarceration Status Verification  SSN will be used to verify
incarceration status
• Income Verification  income data will be compared to
Internal Revenue Service records for tax credit/government-
based healthcare eligibility
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13. D ATA VALIDATION :
A PPLICANT
• The proposed federal data services hub is expected
to have verification services operational for the
open enrollment period beginning on October 1,
2013.
• The Department of Health and Human Services
(HHS) has contracted with Quality Software
Services, Inc. to “build and support the operations
of a federal data service hub that will provide data
verification to support eligibility processes for all
Exchanges, Medicaid, and CHIP.”
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14. D ATA VALIDATION :
E MPLOYER -S PONSORED C OVERAGE
Data validation for employer-sponsored coverage by Exchange:
• Employee Information  compared to either the employer
provided information or to a governmental agency
• Employer Information  compared to governmental
agencies, such as the Department of the Treasury,
Department of Labor, and the Social Security Administration
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15. D ATA VALIDATION :
E MPLOYER -S PONSORED C OVERAGE
• HHS expects the infrastructure for an authoritative
data source to be in place by 2016.
• In the interim, for the plan years 2014-2015, HHS is
seeking ideas from various stakeholders (e.g.,
employers, the health care industry, and other
government agencies) on this topic.
• Through the federal rulemaking process there have
been several options proposed for the interim
process for employment verification.
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16. D ATA VALIDATION :
R ISK A DJUSTMENT
Please refer • HHS proposed risk adjustment data validation process will
to our
include the following steps:
previous
piece on 1. Sample Selection
Risk and 2. Initial Validation Audit
Reinsurance 3. Second Validation Audit
for more
information 4. Error Estimation
on the Risk 5. Appeals
Adjustment 6. Payment Adjustments
Programs.
• After data validation, the state/HHS will be able to adjust
the average actuarial risk of each plan or payments/charges
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based on risk changes

17. REPORTING REQUIREMENTS
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18. R EPORTING R EQUIREMENTS :
E NROLLMENT D ATA
Exchanges and health plan issuers must report
enrollment data for each of the following to HHS:
• Individual applicants (unemployed or enrolling in
insurance not through an employer)
o Name, address, household income, household size ,
proof of citizenship/immigration status
• Employers
o Employer name, address and contact information
o Employee roster and number of employees
• Employees
PAGE 18 o Name, address, contact information, DOB, dependent
information

19. R EPORTING R EQUIREMENTS :
I SSUER D ATA
Issuers in each state that offer the three largest
health insurance products must submit the following
information to HHS:
• Information that identifies their individual health
plans
• Descriptive data of the health plans
• Information on any treatment limitations
• Information about plan drug coverage
• Information about plan enrollment
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20. R EPORTING R EQUIREMENTS :
F INANCIAL D ATA
ACA §1313 – Financial integrity
• Exchanges must account for expenditures and all activities and
submit annual reports to HHS
• HHS audits Exchanges annually
• GAO Comptroller General can conduct studies of Exchange
operations
ACA §10109 – Development of standards for financial and
administrative transactions
• Standard application process
• Greater transparency for claim edits
• Standardized forms for required financial audits
• Standards on whether timeliness of payment rules should be
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published by health plans

21. KEY DATES
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22. K EY D ATES :
S YSTEMS & R EPORTING
DATE EVENT
April 1 Beginning in 2012, drug manufacturers/distributors are required
to send annual reports to HHS on drug sample requests and
distributions from the previous year.
June 30 Beginning in 2012, annual reports from PBM due to HHS.
March 31, 2013 Annual reports on physician payments due to HHS from
and on the 90th day manufacturers for the previous year.
of every year
following
December 31, 2013 Health plans must certify that data and information systems are
in compliance with applicable standards and operating rules for:
• Health plan eligibility,
• Health claim status,
• EFTs, and
• Health care payment and remittance advice.
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23. K EY D ATES :
S YSTEMS & R EPORTING
DATE EVENT
January 1, 2014 Operating rules and standards for EFT and remittance advice in
effect .
January 31 Beginning 2015, employers are to annually file a report with the
IRS certifying employee enrollment in minimum essential
coverage through an employer-sponsored plan for the previous
year.
December 31, 2015 Health plans must certify data and information systems are in
compliance with applicable standards and operating rules for:
Health claims or equivalent encounter information,
Enrollment and disenrollment in a health plan,
Health plan premium payments,
Referral certification and authorization, and
Health claims attachments .
January 1, 2016 Operating rules for all health plan certification as described
above are in effect.
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24. R EED & A SSOCIATES , CPA S
For more information on Reed & Associates, CPAs please
contact us at:
inquire@reedassociatescpas.com
Phone: 860-395-1996
Or visit our website:
reedassociatescpas.com
PAGE 24
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