42 U.S.C. § 18033 — Financial integrity
submitted 16 years ago by Pub. L. 111-148 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 640 words · no verdicts yet
Exchanges must keep accurate financial records, submit yearly reports, and undergo annual federal audits, and the Secretary can withhold state payments for serious misconduct. Exchange payments count as federal claims, so breaking eligibility rules can trigger tripled-to-sextupled False Claims Act penalties, and the GAO must study Exchange operations and costs over time.
(a) Accounting for expenditures
An Exchange must keep accurate records of everything it does, receives, and spends, and report on this to the Secretary* every year. The Secretary, working with the HHS Inspector General, can investigate an Exchange, examine its property and records, and demand regular reports; the Exchange must fully cooperate. The Secretary must audit every Exchange each year. If the Secretary finds serious misconduct by an Exchange or a state*, the Secretary can withhold up to 1 percent per year of that state's payments under this or other HHS-run laws, until the state fixes the problem to the Secretary's satisfaction. The Secretary must run Exchange activities fairly and without discrimination, and put in place any measures needed to cut fraud and abuse that the Secretary is legally allowed to use.
Payments made by or through an Exchange are covered by the False Claims Act if they include any federal money. Following the eligibility rules to receive Exchange payments, including premium tax credits and cost-sharing* reduction payments, counts as a "material condition" for getting paid; breaking that condition can trigger False Claims Act liability. If someone is found liable under the False Claims Act this way, the normal civil penalty is multiplied: it must be increased to between 3 and 6 times the government's actual damages.
(b) GAO oversight
Within 5 years after Exchanges are first required to be running, the Comptroller General, who leads the GAO, must study Exchange activities and enrollees on an ongoing basis. The study must look at: how Exchanges operate and are run, including plan experience data, Exchange expenses, claims statistics, complaint data, and how well Exchanges meet their goals; notable trends in Exchange use; recommended improvements; the cost and affordability of coverage for small-business owners and employees, comparing Exchange and non-Exchange buyers; and how many doctors, by area and specialty, are turning away new patients enrolled in federal health programs, and whether provider networks are adequate.
An Exchange shall keep an accurate accounting of all activities, receipts, and expenditures and shall annually submit to the Secretary* a report concerning such accountings.
The Secretary, in coordination with the Inspector General of the Department of Health and Human Services, may investigate the affairs of an Exchange, may examine the properties and records of an Exchange, and may require periodic reports in relation to activities undertaken by an Exchange. An Exchange shall fully cooperate in any investigation conducted under this paragraph.
An Exchange shall be subject to annual audits by the Secretary.
If the Secretary determines that an Exchange or a State* has engaged in serious misconduct with respect to compliance with the requirements of, or carrying out of activities required under, this title,1 the Secretary may rescind from payments otherwise due to such State involved under this or any other Act administered by the Secretary an amount not to exceed 1 percent of such payments per year until corrective actions are taken by the State that are determined to be adequate by the Secretary.
With respect to activities carried out under this title,1 the Secretary shall provide for the efficient and non-discriminatory administration of Exchange activities and implement any measure or procedure that—
the Secretary determines is appropriate to reduce fraud and abuse in the administration of this title; 1 and
the Secretary has authority to implement under this title 1 or any other Act.
Payments made by, through, or in connection with an Exchange are subject to the False Claims Act (31 U.S.C. 3729 et seq.) if those payments include any Federal funds. Compliance with the requirements of this Act concerning eligibility for a health insurance issuer* to participate in the Exchange shall be a material condition of an issuer’s entitlement to receive payments, including payments of premium tax credits and cost-sharing* reductions, through the Exchange.
Notwithstanding paragraph (1) of section 3729(a) of title 31, and subject to paragraph (2) of such section, the civil penalty assessed under the False Claims Act on any person found liable under such Act as described in subparagraph (A) shall be increased by not less than 3 times and not more than 6 times the amount of damages which the Government sustains because of the act of that person.
Not later than 5 years after the first date on which Exchanges are required to be operational under this title,1 the Comptroller General shall conduct an ongoing study of Exchange activities and the enrollees in qualified health plans offered through Exchanges. Such study shall review—
the operations and administration of Exchanges, including surveys and reports of qualified health plans offered through Exchanges and on the experience of such plans (including data on enrollees in Exchanges and individuals purchasing health insurance coverage* outside of Exchanges), the expenses of Exchanges, claims statistics relating to qualified health plans, complaints data relating to such plans, and the manner in which Exchanges meet their goals;
any significant observations regarding the utilization and adoption of Exchanges;
where appropriate, recommendations for improvements in the operations or policies of Exchanges;
a survey of the cost and affordability of health care insurance provided under the Exchanges for owners and employees of small business concerns (as defined under section 632 of title 15), including data on enrollees in Exchanges and individuals purchasing health insurance coverage outside of Exchanges; and
how many physicians, by area and specialty, are not taking or accepting new patients enrolled in Federal Government health care programs, and the adequacy of provider networks of Federal Government health care programs.
Source credit: (Pub. L. 111–148, title I, § 1313, title X, § 10104(k), Mar. 23, 2010, 124 Stat. 184, 902.)
- 2010Enacted · Pub. L. 111-148 · 124 Stat. 184, 902
A history note hasn’t been published yet. The record shows enactment by Pub. L. 111-148 on 2010-03-23.
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