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Spending in the Early Retiree Reinsurance and Pre-existing Condition 
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United States Government Accountability Office: 
GAO: 

Report to the Ranking Member, Committee on Finance, U.S. Senate: 

April 2013: 

Patient Protection and Affordable Care Act: 

Enrollment and Spending in the Early Retiree Reinsurance and Pre-
existing Condition Insurance Plan Programs: 

GAO-13-391: 

GAO Highlights: 

Highlights of GAO-13-391, a report to the Ranking Member, Committee on 
Finance, U.S. Senate. 

Why GAO Did This Study: 

In March 2010, the Patient Protection and Affordable Care Act (PPACA) 
appropriated $5 billion each to establish and carry out two temporary 
programs—-ERRP and PCIP. ERRP reimburses sponsors of employment-based 
health plans to help cover the cost of providing health benefits to 
early retirees—-individuals age 55 and older not eligible for 
Medicare. The PCIP program is a high-risk pool that provides access to 
health insurance for individuals unable to acquire affordable coverage 
due to a preexisting condition. Both programs are operated by CCIIO 
within CMS (an agency within the Department of Health and Human 
Services) and are intended to operate through 2013, after which PPACA 
will provide new insurance coverage options. 

GAO was asked to provide updated information on ERRP and PCIP 
spending. This report describes the current status of ERRP and PCIP 
enrollment and spending as well as projected PCIP spending and how 
CCIIO is ensuring that program funding is sufficient through 2013. GAO 
obtained the most recent data available on ERRP and PCIP enrollment 
and spending and on overpayments recovered from ERRP plan sponsors 
during the claims adjudication process. GAO also obtained other 
supporting documentation where available. GAO interviewed CMS 
officials about ERRP and PCIP enrollment and spending as well as their 
predictions of future PCIP spending and steps they are taking to 
ensure the sufficiency of PCIP funding. 

The Department of Health and Human Services provided technical 
comments on a draft of this report, which GAO incorporated as 
appropriate. 

What GAO Found: 

The Center for Consumer Information and Insurance Oversight (CCIIO) 
discontinued enrollment in the Early Retiree Reinsurance Program 
(ERRP) in early 2011 and stopped most program reimbursements the 
following year to keep spending within the $5 billion ERRP 
appropriation. Specifically, anticipating exhaustion of funds, CCIIO 
stopped ERRP enrollment in May 2011. According to CCIIO officials, 
CCIIO suspended making reimbursements to plan sponsors in September 
2012, as reimbursements had reached the $4.7 billion cap established 
for paying claims under the original appropriation, and the remainder 
was reserved for administrative expenses. When the cap was reached, 
significant demand for the program remained with 5,699 ERRP 
reimbursement requests left outstanding that accounted for about $2.5 
billion in unpaid claims. CCIIO officials told GAO that they planned 
to pay some of the outstanding reimbursement requests by 
redistributing any overpayments recovered from plan sponsors-—when, 
for example a plan receives a rebate that lowers the total cost of a 
prior claim—-as well as money recovered from program audits. As of 
January 2013, officials told GAO that CCIIO had recovered a total of 
$54 million and redistributed $20.7 million of this amount. 

Enrollment and spending for the Pre-existing Condition Insurance Plan 
(PCIP) program have grown substantially. Cumulative PCIP enrollment 
had reached 103,160 by the end of December 2012, more than doubling 
from a year earlier. By the end of January 2013, total PCIP spending 
reached about $2.6 billion, representing over half of the $5 billion 
PCIP appropriation compared to a year earlier when only about 16 
percent of the total appropriation had been spent. PCIP spending has 
varied on a monthly basis, but overall, monthly spending also has 
increased over the life of the program. Most recently, monthly 
spending reached its highest point since the program’s inception, 
increasing about 35 percent from December 2012 to January 2013. 

According to CMS, PCIP spending is likely to approach the $5 billion 
appropriation by the end of 2013, and CCIIO is taking steps intended 
to ensure it does not exceed this amount. In June 2012, Office of the 
Actuary (OACT) within the Centers for Medicare & Medicaid Services 
(CMS) released a projection that the entire $5 billion in PCIP funding 
would be used “through 2013.” Similarly, CCIIO officials told GAO they 
anticipate total PCIP spending to closely approach $5 billion, and 
that they are taking program management steps—-many of which are not 
yet reflected in spending data-—to ensure appropriated funding lasts 
through 2013. For example, in the second half of 2012, CCIIO was able 
to obtain lower provider reimbursement rates for the PCIP program. 
Also, in January 2013, CCIIO instituted benefit changes that shifted 
more costs onto PCIP enrollees, including by increasing enrollee 
coinsurance from 20 percent to 30 percent in many states. Due to 
growing concerns about the rate of PCIP spending, in February 2013, 
CCIIO suspended PCIP enrollment to ensure the appropriated funding 
would be sufficient to cover claims for current enrollees through the 
end of the program. Officials told GAO that if spending trends begin 
to indicate that funding will not be used as quickly as they are 
projecting, they could reinstate PCIP enrollment to use remaining 
funds. 

View [hyperlink, http://www.gao.gov/products/GAO-13-391]. For more 
information, contact John E.Dicken at (202) 512-7114 or 
dickenj@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

CCIIO Discontinued ERRP Enrollment in Early 2011 and Stopped Most 
Reimbursements the Following Year to Keep Spending within the $5 
Billion Appropriation: 

PCIP Enrollment and Spending Have Grown Substantially: 

PCIP Spending Is Likely to Approach the $5 Billion Appropriation in 
2013, and CCIIO Is Taking Steps Intended to Ensure Spending Does Not 
Exceed This Amount: 

Agency Comments: 

Appendix I: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Figures: 

Figure 1: Cumulative Pre-existing Condition Insurance Plan (PCIP) 
Enrollment, July 2010 through December 2012: 

Figure 2: Cumulative Pre-existing Condition Insurance Plan (PCIP) 
Spending, December 2010 to January 2013: 

Figure 3: Monthly Pre-existing Condition Insurance Plan (PCIP) 
Spending, January 2011 to January 2013: 

Abbreviations: 

CCIIO: Center for Consumer Information and Insurance Oversight: 

CMS: Centers for Medicare & Medicaid Services: 

ERRP: Early Retiree Reinsurance Program: 

GEHA: Government Employees Health Association, Inc. 

HHS: Department of Health and Human Services: 

OACT: Office of the Actuary: 

PCIP: Pre-existing Condition Insurance Plan: 

PPACA: Patient Protection and Affordable Care Act: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

April 30, 2013: 

The Honorable Orrin G. Hatch: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

Dear Senator Hatch: 

In March 2010, the Patient Protection and Affordable Care Act (PPACA) 
appropriated $5 billion each to establish and carry out two temporary 
programs, the Early Retiree Reinsurance Program (ERRP) and the Pre-
existing Condition Insurance Plan (PCIP) program.[Footnote 1] The 
programs are intended to provide access to health insurance coverage 
for early retirees--individuals age 55 and older who are not eligible 
for Medicare--and individuals with preexisting medical conditions, 
respectively.[Footnote 2] Both populations historically have faced 
challenges obtaining health insurance in the individual market due, 
among other things, to being charged higher premiums than younger or 
healthier individuals on the basis of age or health status, or to 
being denied coverage altogether.[Footnote 3] In addition, while some 
early retirees may have access to health insurance through their 
employer, the number of large employers offering retiree coverage has 
been declining.[Footnote 4] ERRP and the PCIP program are intended to 
operate through December 31, 2013, after which new coverage options 
will become available through PPACA's health insurance Exchanges. 
[Footnote 5] 

ERRP provides reimbursement to participating employment-based health 
plans that is intended to cover a portion of the cost of providing 
health benefits to early retirees in order to help employers continue 
to offer these benefits and provide financial relief to plan 
participants.[Footnote 6] Under the program, sponsors of health plans--
which can include commercial organizations, government entities, 
nonprofit organizations, religious organizations, and unions--may use 
ERRP reimbursements to reduce their costs for providing health 
benefits, plan participants' health benefit costs, or any combination 
of these costs.[Footnote 7] The PCIP program is a high-risk pool that 
provides access to health insurance at standard market rates for 
individuals unable to acquire affordable coverage due to a preexisting 
condition.[Footnote 8] 

In order to carry out responsibilities under various provisions of 
PPACA, including ERRP and the PCIP program, the Department of Health 
and Human Services (HHS) created the Center for Consumer Information 
and Insurance Oversight (CCIIO) in April 2010.[Footnote 9] CCIIO began 
ERRP enrollment in June 2010 and PCIP enrollment shortly after in July 
2010. We reported in September 2011 on various aspects of ERRP, 
including CCIIO's process for implementing the program, initial 
program expenditures and the types of plan sponsors enrolled, and how 
plan sponsors intended to use ERRP reimbursements.[Footnote 10] Also 
in 2011, we reported on various aspects of the PCIP program, including 
initial enrollment and spending trends, program features, and CCIIO's 
oversight.[Footnote 11] 

Because ERRP and the PCIP program were each appropriated a fixed 
amount of money, questions have been raised about the rate of spending 
and how long the funding would last. For example, while enrollment in 
the PCIP program has been lower than initially projected, per member 
per month claim costs have been higher than expected, leading some to 
question whether spending could exhaust its $5 billion appropriation 
as enrollment continues to grow.[Footnote 12] You asked us to provide 
updated information on spending for ERRP and the PCIP program. In this 
report, we describe: 

1. the current status of ERRP enrollment and spending, 

2. the current status of PCIP enrollment and spending, and: 

3. projected PCIP spending and how CCIIO is ensuring that program 
funding is sufficient through 2013. 

To describe the current status of ERRP enrollment and spending, we 
obtained cumulative enrollment and spending data from CCIIO through 
October 2012 or the most recent data available at the time of our 
analysis.[Footnote 13] We also obtained information as of January 2013 
on funds recovered from ERRP plan sponsors from overpayments 
identified through the claims adjudication process. We interviewed 
CCIIO officials about ERRP enrollment and spending and obtained 
supporting documentation where available, such as answers to 
frequently asked questions on ERRP's website. We also interviewed 
knowledgeable agency officials about their efforts to ensure the 
quality of the enrollment and spending data and checked for anomalies. 
We determined these data were sufficiently reliable for our purposes. 

To describe the current status of PCIP enrollment and spending, we 
obtained monthly enrollment data through December 2012 and spending 
data through January 2013 from CCIIO, the most recent data available 
at the time of our analysis. We interviewed CCIIO officials about PCIP 
enrollment and spending and obtained supporting documentation where 
available, such as PCIP policies and procedures. We also interviewed 
knowledgeable agency officials about their efforts to ensure the 
quality of the enrollment and spending data and checked for anomalies. 
We determined these data were sufficiently reliable for our purposes. 

To describe projected PCIP spending and how CCIIO is ensuring that 
program funding is sufficient through 2013, we interviewed CCIIO 
officials about their estimates of future PCIP spending as well as 
steps they are taking to ensure program funding is sufficient through 
2013. In addition, we discussed estimates of PCIP spending through 
2013 with officials from the Office of the Actuary (OACT) within the 
Centers for Medicare & Medicaid Services (CMS). We obtained supporting 
documentation where possible, such as documents containing PCIP 
benefit changes. 

We conducted this performance audit from December 2012 to March 2013 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

ERRP: 

In implementing ERRP, CCIIO is responsible for, among other things, 
determining which plan sponsors are eligible to participate in the 
program and providing reimbursements to the participating sponsors. 
Eligibility for participation is determined by a plan sponsor meeting 
a number of requirements, including being able to document claims, 
implement programs and procedures that have the potential to generate 
cost savings for plan participants with chronic and high-cost 
conditions, and having policies and procedures in place to detect and 
reduce fraud, waste, and abuse. When requesting reimbursement, 
sponsors must provide documentation of the cost of medical claims, 
[Footnote 14] which can include costs paid by early retirees in the 
form of deductibles, copayments, or coinsurance. For eligible claims 
paid by a plan on behalf of each early retiree, CCIIO will reimburse 
80 percent of the amount that exceeded $15,000 (the cost threshold) 
but was not greater than $90,000 (the cost limit) in a given year. 
[Footnote 15] ERRP reimbursement requests are paid in the order in 
which they are received, and CCIIO may stop taking ERRP applications 
or, if an application is approved, deny all or part of a reimbursement 
request, based on the availability of funding.[Footnote 16] 

Plan sponsors are not required to use ERRP reimbursements by the end 
of the plan year in which they are provided, but are expected to use 
reimbursements as soon as possible and no later than December 31, 
2014.[Footnote 17] Under PPACA, plan sponsors can use the 
reimbursements to reduce their own premium contributions or other 
health benefit costs; reduce plan participants' premium contributions, 
copayments, deductibles, coinsurance, or other out-of-pocket costs; or 
reduce any combination of these costs.[Footnote 18] However, sponsors 
are not permitted to use the funds received as general revenue, and 
thus must maintain the same level of contribution toward the plan as 
they did prior to applying to enroll in ERRP. CCIIO may conduct audits 
of plan sponsors to verify their compliance with this and other 
program requirements. 

PCIP: 

To be eligible for PCIP, individuals must have a preexisting condition 
and have been without creditable coverage for at least 6 months prior 
to application.[Footnote 19] This requirement effectively prevents 
enrollment by those who were already insured, thus limiting the 
program to individuals who likely have been unable to access insurance 
because of their preexisting condition.[Footnote 20] PCIP programs 
must not impose waiting periods for coverage based on the enrollee's 
preexisting condition, and plan benefits must cover at least 65 
percent of the total cost of coverage until enrollees hit a statutory 
out-of-pocket spending limit, at which point PCIP covers 100 percent 
of the cost. PPACA requires that HHS develop procedures to transition 
PCIP enrollees from the program to the Exchanges when they begin in 
2014 and that such procedures ensure these enrollees do not experience 
a lapse in coverage.[Footnote 21] At the same time, if HHS estimates 
that, for any fiscal year, PCIP funding will be insufficient to cover 
the payment of claims, PPACA authorizes it to make such adjustments as 
are necessary to eliminate this deficit and to stop PCIP enrollment. 
[Footnote 22] 

To begin implementing the PCIP program, CCIIO determined a state-by-
state allocation of the total $5 billion PCIP appropriation. The 
initial allocations were based on a formula similar to that used for 
the Children's Health Insurance Program, using factors that reflected 
each state's population, number of uninsured individuals under age 65, 
and a geographic variation in the cost of care.[Footnote 23] In 
addition, states were given the option to operate their own PCIP with 
federal funding, or to allow HHS to operate the PCIP in their state. 
Twenty-seven states elected to operate a PCIP for their residents, 
while 23 states and the District of Columbia opted to allow HHS to 
operate their PCIPs. For the 27 states that chose to operate their own 
PCIPs, HHS directly contracted with states or their designated 
nonprofit entities. The contracts established that HHS would reimburse 
states or their designated entities for claims and administrative 
costs incurred in excess of the premiums they collected. To implement 
the federally run PCIP for the 24 states that opted not to operate 
their own PCIP, HHS coordinated with other federal agencies and 
selected the Government Employees Health Association, Inc. (GEHA) to 
help operate the program. GEHA was awarded a cost-plus-award fee 
contract, which established that HHS would reimburse GEHA for claims 
and administrative costs in addition to granting fixed and performance-
based award fees.[Footnote 24] For both the federally and state-run 
PCIPs, HHS established a limit on administrative costs of no more than 
10 percent of total spending over the lifetime of the program. 

CCIIO Discontinued ERRP Enrollment in Early 2011 and Stopped Most 
Reimbursements the Following Year to Keep Spending within the $5 
Billion Appropriation: 

CCIIO stopped accepting applications for ERRP enrollment in May 2011, 
anticipating the $5 billion appropriation would be exhausted. As we 
previously reported, at that time the total number of approved plan 
sponsors was more than 6,000--most of which enrolled within the first 
6 months of the program--and CCIIO had already spent $2.4 billion 
reimbursing plan sponsors for claims incurred.[Footnote 25] Officials 
told us that in September 2012, CCIIO suspended making reimbursements 
to plan sponsors, with reimbursements having exceeded the $4.7 billion 
cap established for paying claims under the original appropriation 
nearly a year earlier.[Footnote 26] In anticipation of exceeding the 
cap, CCIIO had issued guidance on December 13, 2011, stating that it 
would not accept reimbursement requests for ERRP claims incurred after 
December 31, 2011.[Footnote 27] However, the program continued to 
accept requests for claims incurred on or before this date and 
officials explained that a number of factors led to it taking until 
September 2012 for all $4.7 billion to be spent, including that 
reimbursements must go through a clearance process to make sure funds 
are paid appropriately. When the $4.7 billion was reached, significant 
demand for the program remained with 5,699 ERRP reimbursement requests 
left outstanding that accounted for about $2.5 billion in unreimbursed 
claims.[Footnote 28] 

CCIIO is recovering portions of the $4.7 billion from plan sponsors 
that were overpaid and using those funds to pay outstanding 
reimbursement requests in the order in which they were received. 
Overpayments are identified through the claims adjudication process 
and can happen when, for example, a plan receives a rebate from a 
provider that lowers the total cost of a claim after the claim was 
initially submitted to ERRP. In addition, because early reimbursement 
requests were based on summary claims data, CCIIO required plan 
sponsors to submit a more detailed accounting of the actual costs of 
these requests by April 27, 2012.[Footnote 29] Officials told us that 
if an overpayment was identified for a reimbursement request, or if 
sponsors failed to meet the April deadline, costs associated with that 
request were to be recovered by CCIIO. As of January 2013, CCIIO had 
identified $60.2 million in overpayments and recovered $54 million of 
this amount. CCIIO was pursuing collection of the remaining $6.2 
million and estimated that as much as an additional $15 million in 
overpayments may be identified and collected in fiscal year 2013. 

In addition to recovering overpayments, officials told us that any 
money recovered from program audits would also be used to pay 
outstanding reimbursement requests. CCIIO hired a contractor with a 
goal of conducting audits of 30 ERRP plan sponsors that officials said 
account for 30 percent of program reimbursements. As of January 2013, 
CCIIO had initiated 17 audits, but had not yet received any audit 
reports from the contractor. Consequently, officials told us that they 
were not yet able to estimate how much recovered ERRP funds would be 
identified through this process. 

PCIP Enrollment and Spending Have Grown Substantially: 

PCIP enrollment has grown substantially. By the end of December 2012, 
cumulative enrollment had reached 103,160, up more than 50,000 from a 
year earlier when enrollment was 48,862. (See figure 1.) Enrollment in 
state-run PCIPs represents a larger percentage of total enrollment 
compared to the federally run PCIP; however, the federally run PCIP 
has accounted for an increasing percentage of the total over time. 
When we last reported on the PCIP program, as of April 2011, 
enrollment in the federally run PCIP represented about 26 percent of 
total enrollment; by the end of December 2012, it represented about 43 
percent.[Footnote 30] CCIIO officials told us that their decision to 
accept, starting in July 2011, a letter from a health care provider as 
proof of a preexisting condition in the federally run PCIP likely 
contributed to this shift--although CCIIO later reversed this decision 
in May 2012.[Footnote 31] Similar to prior months, PCIP enrollment 
continued to vary widely across states, ranging from 1 in Vermont to 
15,101 in California.[Footnote 32] 

Figure 1: Cumulative Pre-existing Condition Insurance Plan (PCIP) 
Enrollment, July 2010 through December 2012: 

[Refer to PDF for image: stacked vertical bar graph] 

Enrollees: 

Date: July 2010; 
State-run: 23; 
Federally run: 0. 

Date: August 2010; 
State-run: 277; 
Federally run: 299. 

Date: September 2010; 
State-run: 1,849; 
Federally run: 924. 

Date: October 2010; 
State-run: 4,809; 
Federally run: 1,506. 

Date: November 2010; 
State-run: 6,071; 
Federally run: 2,040. 

Date: December 2010; 
State-run: 8,735; 
Federally run: 2,596. 

Date: January 2011; 
State-run: 10,218; 
Federally run: 3,162. 

Date: February 2011; 
State-run: 11,742; 
Federally run: 3,785. 

Date: March 2011; 
State-run: 13,407; 
Federally run: 4,753. 

Date: April 2011; 
State-run: 15,661; 
Federally run: 5,673. 

Date: May 2011; 
State-run: 17,791; 
Federally run: 6,682. 

Date: June 2011; 
State-run: 19,702; 
Federally run: 7,556. 

Date: July 2011; 
State-run: 21,550; 
Federally run: 8,712. 

Date: August 2011; 
State-run: 23,361; 
Federally run: 10,588. 

Date: September 2011; 
State-run: 25,262; 
Federally run: 12,340. 

Date: October 2011; 
State-run: 27,307; 
Federally run: 14,122. 

Date: November 2011; 
State-run: 29,093; 
Federally run: 15,750. 

Date: December 2011; 
State-run: 31,205; 
Federally run: 17,657. 

Date: January 2012; 
State-run: 33,222; 
Federally run: 18,878. 

Date: February 2012; 
State-run: 35,145; 
Federally run: 21,112. 

Date: March 2012; 
State-run: 37,823; 
Federally run: 23,796. 

Date: April 2012; 
State-run: 40,888; 
Federally run: 26,594. 

Date: May 2012; 
State-run: 43,781; 
Federally run: 29,552. 

Date: June 2012; 
State-run: 46,441; 
Federally run: 31,436. 

Date: July 2012; 
State-run: 48,418; 
Federally run: 33,582. 

Date: August 2012; 
State-run: 50,682; 
Federally run: 35,390. 

Date: September 2012; 
State-run: 53,043; 
Federally run: 37,286. 

Date: October 2012; 
State-run: 54,707; 
Federally run: 39,751. 

Date: November 2012; 
State-run: 56,950; 
Federally run: 42,515. 

Date: December 2012; 
State-run: 58,726; 
Federally run: 44,434. 

Source: GAO analysis of CCIIO data. 

[End of figure] 

By the end of January 2013, cumulative PCIP spending reached about 
$2.6 billion, representing over half of the $5 billion appropriated 
for the program.[Footnote 33] This represents a substantial increase 
from a year earlier when about $782 million had been spent, 
representing about 16 percent of the total appropriation. (See figure 
2.) Similar to the trend in enrollment, the federally run PCIP has 
accounted for an increasing percentage of total program spending. The 
percentage of PCIP spending used for administrative costs has declined 
over time and by the end of December 2012 it had fallen to about 7 
percent.[Footnote 34] 

Figure 2: Cumulative Pre-existing Condition Insurance Plan (PCIP) 
Spending, December 2010 to January 2013: 

[Refer to PDF for image: vertical bar graph] 

Date: December 2010; 
Cumulative Program Total Spending: $0.03 billion. 

Date: January 2011; 
Cumulative Program Total Spending: $0.04 billion. 

Date: February 2011; 
Cumulative Program Total Spending: $0.07 billion. 

Date: March 2011; 
Cumulative Program Total Spending: $0.10 billion. 

Date: April 2011; 
Cumulative Program Total Spending: $0.13 billion. 

Date: May 2011; 
Cumulative Program Total Spending: $0.18 billion. 

Date: June 2011; 
Cumulative Program Total Spending: $0.22 billion. 

Date: July 2011; 
Cumulative Program Total Spending: $0.27 billion. 

Date: August 2011; 
Cumulative Program Total Spending: $0.34 billion. 

Date: September 2011; 
Cumulative Program Total Spending: $0.41 billion. 

Date: October 2011; 
Cumulative Program Total Spending: $0.48 billion. 

Date: November 2011; 
Cumulative Program Total Spending: $0.60 billion. 

Date: December 2011; 
Cumulative Program Total Spending: $0.69 billion. 

Date: January 2012; 
Cumulative Program Total Spending: $0.78 billion. 

Date: February 2012; 
Cumulative Program Total Spending: $0.88 billion. 

Date: March 2012; 
Cumulative Program Total Spending: $0.98 billion. 

Date: April 2012; 
Cumulative Program Total Spending: $1.10 billion. 

Date: May 2012; 
Cumulative Program Total Spending: $1.24 billion. 

Date: June 2012; 
Cumulative Program Total Spending: $1.42 billion. 

Date: July 2012; 
Cumulative Program Total Spending: $1.58 billion. 

Date: August 2012; 
Cumulative Program Total Spending: $1.74 billion. 

Date: September 2012; 
Cumulative Program Total Spending: $1.90 billion. 

Date: October 2012; 
Cumulative Program Total Spending: $2.05 billion. 

Date: November 2012; 
Cumulative Program Total Spending: $2.24 billion. 

Date: December 2012; 
Cumulative Program Total Spending: $2.41 billion. 

Date: January 2013; 
Cumulative Program Total Spending: $2.63 billion. 

Source: GAO analysis of CCIIO data. 

Notes: Data for monthly cumulative PCIP spending are not available 
prior to December 2010. 

[End of figure] 

Spending data do not include administrative costs for HHS staff 
salaries and benefits, compliance and oversight, general information 
technology, and outreach; however, officials estimated that these 
costs were approximately $12 million for fiscal years 2011 and 2012. 
Spending data are net of any premium revenue collected from enrollees. 

PCIP spending has varied on a monthly basis, but overall, monthly 
spending also has increased over the life of the program. Most 
recently, monthly spending reached its highest point since the 
program's inception, increasing about 35 percent from the end of 
December 2012 to the end of January 2013. (See figure 3.) 

Figure 3: Monthly Pre-existing Condition Insurance Plan (PCIP) 
Spending, January 2011 to January 2013: 

[Refer to PDF for image: line graph] 

Date: January 2011; 
Disbursements Net of Premiums: $0.16 million. 

Date: February 2011; 
Disbursements Net of Premiums: $0.22 million. 

Date: March 2011; 
Disbursements Net of Premiums: $0.34 million. 

Date: April 2011; 
Disbursements Net of Premiums: $0.33 million. 

Date: May 2011; 
Disbursements Net of Premiums: $0.43 million. 

Date: June 2011; 
Disbursements Net of Premiums: $0.46 million. 

Date: July 2011; 
Disbursements Net of Premiums: $0.45 million. 

Date: August 2011; 
Disbursements Net of Premiums: $0.75 million. 

Date: September 2011; 
Disbursements Net of Premiums: $0.63 million. 

Date: October 2011; 
Disbursements Net of Premiums: $0.80 million. 

Date: November 2011; 
Disbursements Net of Premiums: $1.14 million. 

Date: December 2011; 
Disbursements Net of Premiums: $0.87 million. 

Date: January 2012; 
Disbursements Net of Premiums: $0.96 million. 

Date: February 2012; 
Disbursements Net of Premiums: $0.98 million. 

Date: March 2012; 
Disbursements Net of Premiums: $1.02 million. 

Date: April 2012; 
Disbursements Net of Premiums: $1.17 million. 

Date: May 2012; 
Disbursements Net of Premiums: $1.44 million. 

Date: June 2012; 
Disbursements Net of Premiums: $1.76 million. 

Date: July 2012; 
Disbursements Net of Premiums: $1.57 million. 

Date: August 2012; 
Disbursements Net of Premiums: $1.66 million. 

Date: September 2012; 
Disbursements Net of Premiums: $1.62 million. 

Date: October 2012; 
Disbursements Net of Premiums: $1.52 million. 

Date: November 2012; 
Disbursements Net of Premiums: $1.84 million. 

Date: December 2012; 
Disbursements Net of Premiums: $1.68 million. 

Date: January 2013; 
Disbursements Net of Premiums: $2.26 million. 

Source: GAO analysis of CCIIO data. 

Notes: Data for monthly PCIP spending are not available prior to 
January 2011. 

[End of figure] 

Spending data do not include administrative costs for HHS staff 
salaries and benefits, compliance and oversight, general information 
technology, and outreach; however, officials estimated that these 
costs were approximately $12 million for fiscal years 2011 and 2012. 
Spending data are net of any premium revenue collected from enrollees. 

PCIP spending also varied across states, with some states spending 
more than they were originally allocated and some states spending 
less. For example, CCIIO officials said that as of January 2013, three 
states--New Hampshire, South Dakota, and Utah--have spent more money 
than they were originally allocated because of higher than expected 
enrollment or per member costs. Additionally, CCIIO has obligated to 
five states--Alaska, Colorado, Montana, Oregon, and New Mexico--more 
funding in 2012 than was in their original allocation, but these 
states have yet to spend the additional funds. Officials also said 
that other states have had lower than expected expenditures--for 
example, North Carolina was originally allocated $145 million, but, 
through December 2012, had only spent about $26 million due primarily 
to lower than expected enrollment. Thus, officials said that CCIIO 
reallocated money originally intended for these states to the states 
that were exceeding their expenditure projections. 

PCIP Spending Is Likely to Approach the $5 Billion Appropriation in 
2013, and CCIIO Is Taking Steps Intended to Ensure Spending Does Not 
Exceed This Amount: 

According to CMS, PCIP spending is likely to approach the $5 billion 
appropriation in 2013. In June 2012, CMS's OACT released a projection 
of PCIP spending, and reported the entire $5 billion in funding would 
be used "through 2013." When asked for more specifics, OACT officials 
told us that this projection was not intended to produce a point-in-
time estimate for when the program would run out of money, but rather 
represents their expectation that the entire $5 billion appropriation 
would be needed to pay for care provided through 2013. Officials also 
said that their projection was informed by historical enrollment, 
cost, and utilization data, as well as discussions with CCIIO staff 
about program experience. Officials noted that the historical data 
they used were through February 2012--the most recent program data 
available at that time. 

CCIIO officials similarly told us that they anticipate total PCIP 
spending will be close to $5 billion, and that they are taking program 
management steps--many of which are not yet reflected in the spending 
data--intended to ensure that the appropriated funding lasts until the 
end of 2013. For example, on behalf of the federally run PCIP, GEHA 
contracted in August 2012 with United Healthcare to access lower 
provider reimbursement rates than those the federally run program had 
previously. While the extent of this rate reduction varies by state, 
officials said that there has been about a 20 percent reduction on 
average. To further reduce rates, GEHA also worked with United 
Healthcare to approach approximately the top 100 hospitals in terms of 
PCIP utilization to attempt to renegotiate federally run PCIP hospital 
facility fees to the same rate as Medicare. According to officials, 
about one quarter of the hospitals approached agreed to the 
renegotiation. Officials told us that some states have similarly 
approached hospitals to lower reimbursement rates, negotiated other 
discounts with providers, or implemented other cost control 
strategies, such as disease management programs. 

More recently, CCIIO instituted benefit changes for the federally run 
PCIP that shifted more costs onto enrollees starting in January 2013. 
For example, it increased enrollees' out of pocket maximum for in-
network services from $4,000 to $6,250 and for out-of-network services 
from $7,000 to $10,000.[Footnote 35] It also increased enrollee 
coinsurance from 20 percent to 30 percent. As another step, CCIIO 
officials said that whereas they had previously had annual contracts 
with states under the PCIP program, in 2013, they moved to quarterly 
contracts that will allow them to allocate funding based on each 
state's near-term expenditures and thus prevent over-obligation of 
funds. Finally, due to growing concerns about the rate of PCIP 
spending, in February 2013, CCIIO suspended PCIP enrollment to ensure 
the appropriated funding would be sufficient to cover claims for 
current enrollees through the end of the program.[Footnote 36] In 
addition, CCIIO requested that state-run PCIPs institute the same 
benefit changes that were instituted in the federally run program in 
January 2013 by April 1, 2013, or the earliest possible date 
thereafter for all of their enrollees. Officials told us that if 
spending trends begin to indicate that funding will not be used as 
quickly as they are projecting, they could reinstate PCIP enrollment 
to use remaining funds.[Footnote 37] 

Agency Comments: 

We provided a draft of this report to HHS for comment. HHS provided 
technical comments, which we incorporated as appropriate. 

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies to the 
Secretary of Health and Human Services and other interested parties. 
In addition, the report will be available at no charge on the GAO 
website at [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or dickenj@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix I. 

Sincerely yours, 

Signed by: 

John E. Dicken Director, Health Care: 

[End of section] 

Appendix I: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

John E. Dicken, (202) 512-7114 or dickenj@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Randy DiRosa, Assistant 
Director; George Bogart; Laura Brogan; Richard Krashevski; Yesook 
Merrill; Laurie Pachter; and Rachel Svoboda made key contributions to 
this report. 

[End of section] 

Related GAO Products: 

Pre-Existing Condition Insurance Plan: Comparison of Implementation 
and Early Enrollment with the Children's Health Insurance Program. 
[hyperlink, http://www.gao.gov/products/GAO-12-62R]. Washington, D.C.: 
November 10, 2011. 

Private Health Insurance: Implementation of the Early Retiree 
Reinsurance Program. [hyperlink, 
http://www.gao.gov/products/GAO-11-875R]. Washington, D.C.: September 
30, 2011. 

Pre-Existing Condition Insurance Plans: Program Features, Early 
Enrollment and Spending Trends, and Federal Oversight Activities. 
[hyperlink, http://www.gao.gov/products/GAO-11-662]. Washington, D.C.: 
July 27, 2011. 

[End of section] 

Footnotes: 

[1] Pub. L. No. 111-148, §§ 1102(e) and1101(g), 124 Stat.143, 145 
(2010).The funds are available without fiscal year limitation. 

[2] Medicare is the federal health insurance program for persons aged 
65 or over, individuals under the age of 65 with certain disabilities, 
and individuals with end-stage renal disease. 

[3] Individuals without employment-based group coverage may buy 
coverage in the private individual market directly from insurers. In 
addition to early retirees, these include the self-employed; those 
whose employers do not offer health insurance coverage; individuals 
not in the labor force; and individuals who lose their jobs and are 
either ineligible for or have exhausted the right to continue their 
employer-based coverage for 18 months. 

We previously reported that 19 percent of applicants in the individual 
market were denied enrollment and a quarter of insurers had denial 
rates of 40 percent or higher, using data collected by the Department 
of Health and Human Services (HHS) for the first quarter of 2010. See 
GAO, Private Health Insurance: Data on Application and Coverage 
Denials, [hyperlink, http://www.gao.gov/products/GAO-11-268] 
(Washington, D.C.: Mar. 16, 2011). 

[4] The number of large employers offering health insurance coverage 
to retirees was 66 percent in 1988, 34 percent in 2000, and 25 percent 
in 2012. See Henry J. Kaiser Family Foundation and Health Research & 
Educational Trust, Employer Health Benefits 2012 Annual Survey (Menlo 
Park, Calif. and Chicago, Ill.: September 2012). Large employers were 
defined as firms with 200 or more employees. 

[5] Starting in 2014, PPACA establishes new options for individuals to 
obtain health insurance coverage through state-based health insurance 
marketplaces called "Exchanges." The law also will prohibit insurers 
in the individual market from denying coverage to individuals with 
preexisting conditions or charging them more in premiums, and limit 
how much insurers can vary what they charge for premiums based on age. 
See Pub. L. No. 111-148, Title I, Subtitles C and D, 124 Stat. 154 et 
seq., as amended by §§ 10103 and 10104, 124 Stat. 892, et seq. 

[6] Under ERRP, health benefits provided to spouses, surviving 
spouses, and dependents of early retirees are also eligible for 
reimbursement, even if these individuals are under the age of 55 or 
are eligible for Medicare. Throughout this report, we use the term 
early retirees to refer to early retirees and their spouses, surviving 
spouses, and dependents. In addition to early retirees, eligible plans 
can also cover active employees and their spouses and dependents as 
well as retirees who are eligible for Medicare. 

[7] Typically, employment-based health plans are not a discrete entity 
to which payments can be directly made. Therefore, in implementing the 
program, the Department of Health and Human Services (HHS) has 
interpreted this provision to require reimbursement to a sponsor, 
which it has defined to mean: a "plan sponsor" as defined in § 
3(16)(B) of the Employee Retirement Income Security Act of 1974, 
except that in the case of a plan maintained jointly by one employer 
and an employee organization and for which the employer is the primary 
source of financing, the term means the employer. Early Retiree 
Reinsurance Program, 75 Fed. Reg. 24450, 24451, 24467 (May 5, 2010) 
(definition of "sponsor" codified at 45 C.F.R. § 149.2). 

[8] The PCIP program was modeled after existing state-operated high-
risk pools, which, as of February 2012, operated in 35 states and 
similarly provide access to coverage for individuals with preexisting 
conditions; however, the PCIP program differs from state-operated high-
risk pools in certain ways. For example, while the PCIP program 
requires that individuals be without health insurance coverage for 6 
months to be eligible, state-operated high-risk pools generally do not 
have such a requirement. Once enrolled, however, many state operated 
pools impose waiting periods of 6 to 12 months for coverage of the 
preexisting condition, while the PCIP program does not impose waiting 
periods. 

PCIP premiums are set at 100 percent of the standard rate for a 
standard population in each state or market, and can vary on the basis 
of age by no more than a 4 to 1 ratio. 

[9] CCIIO was initially known as the Office of Consumer Information 
and Insurance Oversight. Its name was changed to CCIIO in January 2011 
when it was transferred to the Centers for Medicare & Medicaid 
Services (CMS) within HHS. 

[10] See GAO, Private Health Insurance: Implementation of the Early 
Retiree Reinsurance Program, [hyperlink, 
http://www.gao.gov/products/GAO-11-875R] (Washington, D.C.: Sept. 30, 
2011). 

[11] See GAO, Pre-Existing Condition Insurance Plans: Program 
Features, Early Enrollment and Spending Trends, and Federal Oversight 
Activities, [hyperlink, http://www.gao.gov/products/GAO-11-662] 
(Washington, D.C.: July 27, 2011) and Pre-Existing Condition Insurance 
Plan: Comparison of Implementation and Early Enrollment with the 
Children's Health Insurance Program, [hyperlink, 
http://www.gao.gov/products/GAO-12-62R] (Washington, D.C.: Nov. 10, 
2011). 

[12] For example, the Office of the Actuary within CMS initially 
projected that PCIP enrollment would be 375,000 by the end of 2010, 
but the actual number was 9,042. At the same time, in February 2012, 
CCIIO reported that, on average, the PCIP program experienced claims 
costs 2.5 times higher than anticipated. See CCIIO, Covering People 
with Pre-Existing Conditions: Report on the Implementation and 
Operation of the Pre-Existing Condition Insurance Plan Program 
(Washington, D.C: Feb. 23, 2012). 

[13] In addition, we accessed earlier information on ERRP enrollment 
and spending from our 2011 report on ERRP, [hyperlink, 
http://www.gao.gov/products/GAO-11-875R], and CCIIO's website. 

[14] Health costs that are eligible for ERRP reimbursement under PPACA 
include those covered by medical, surgical, hospital, prescription 
drug, and other health benefits as determined by the Secretary of 
Health and Human Services. See Pub. L. No. 111-148, § 1102(a)(2)(A), 
124 Stat. 143. In general, CCIIO applies the Medicare benefit standard 
to determine whether a given item or service is a health benefit and 
thus eligible for ERRP reimbursement. 

[15] Pub. L. No. 111-148, § 1102(c), 124 Stat. 144. Eligible claims 
must be calculated excluding any negotiated price concessions. The 
$15,000 cost threshold and $90,000 cost limit are to be adjusted each 
fiscal year based on the percentage increase in the Medical Care 
Component of the Consumer Price Index for all urban consumers. For 
plan years that started on or after October 1, 2011, the annual cost 
threshold was adjusted to $16,000 and the annual cost limit to $93,000. 

[16] 75 Fed. Reg. 24450, 24466 (May 5, 2010) (codified at 45 C.F.R. § 
149.45(a)). 

[17] While ERRP is scheduled to operate through December 31, 2013, 
CCIIO will allow sponsors until December 31, 2014 to use their 
reimbursements. 

[18] Although plan sponsors can only receive reimbursement for health 
benefit costs paid on behalf of early retirees, plan sponsors who use 
the reimbursements to reduce plan participants' costs must reduce 
costs for all participants, including retirees who are eligible for 
Medicare, active employees, and their spouses and dependents. 

[19] Pub. L. No. 111-148, § 1101(d), 124 Stat.142. Creditable coverage 
is defined for this purpose as coverage for an individual under: a 
group health plan, health insurance, Medicare Part A or B, Medicaid, 
the military health care system, the Indian Health Service, a state 
health benefits high-risk pool, the Federal Employees Health Benefits 
Program, the Peace Corps health benefit plan, or a public health plan 
as defined in regulations. See Public Health Service Act, § 2701(c)(1). 

[20] To be eligible for PCIP, individuals must also be citizens, 
nationals, or lawfully present in the United States, as well as 
residents of the state in which they enroll in the PCIP program. 

[21] Pub. L. No. 111-148 §1101(g)(3)(B), 124 Stat.143. 

[22] Pub. L. No. 111-148 §1101(g)(2),(4), 124 Stat.143. 

[23] The Children's Health Insurance Program is a joint state and 
federal program for uninsured children in families whose incomes are 
too high for Medicaid, but too low to afford private coverage. 

Initial PCIP allocations ranged from $8 million for North Dakota, 
Vermont, and Wyoming to $761 million for California. CCIIO reserves 
the right to reallocate unused funds to states in future years from 
initial allocations and make adjustments as necessary to eliminate any 
potential deficit due to projected expenses exceeding a state's 
allocation. 

[24] The fixed award fee was set at 5 percent of annual projected 
administrative costs. The incentive award fee was based on performance 
measures such as claims processing timeliness and accuracy, care 
management, and cost containment. See 48 C.F.R. § 16.405-2 (2010) 
(Federal Acquisition Regulation §16.405-2) (definition of cost-plus-
award-fee contracts). 

[25] See [hyperlink, http://www.gao.gov/products/GAO-11-875R] for more 
information on initial ERRP enrollment and expenditures. 

While more than 6,000 plan sponsors were approved for ERRP enrollment, 
by the end of October 2012, payments had been made to 2,858 unique 
plan sponsors, which officials said was in part because not all 
sponsors who were approved ended up submitting a reimbursement request. 

[26] Officials told us that at the start of ERRP, CCIIO allocated $4.7 
billion to cover payments to plan sponsors for reimbursement requests 
and the remaining $300 million to cover administrative expenses, such 
as staff salaries, overhead, and contracts for information technology 
and other support services. CCIIO officials told us that they expected 
$300 million to be sufficient to cover administrative expenses through 
the end of the program, noting that such expenses would continue 
through fiscal year 2015. Through the end of fiscal year 2012, CCIIO 
had paid $61.2 million for administrative expenses. 

[27] See Early Retiree Reinsurance Program, Notice, 76 Fed. Reg. 77537 
(Dec. 13, 2011). 

[28] According to CCIIO officials, one reason for the large number of 
outstanding reimbursement requests was that as funding for ERRP ran 
low and CCIIO put out notice that it would no longer be accepting 
claims incurred after December 31, 2011, sponsors rushed to submit 
claims so that they could get paid. Officials also noted that some of 
the outstanding requests are corrections to previously submitted 
claims. By January 2013, 75 reimbursement requests had been made in 
addition to those outstanding when the $4.7 billion cap was reached in 
September 2012, 12 of which were new and 63 of which revised previous 
claims. 

[29] CCIIO officials said that in submitting reimbursement requests 
based on summary claims data, plan sponsors were required to aggregate 
eligible claims for early retirees and provide a Summary Cost Report 
that calculated the ERRP reimbursement amount. Subsequently, CCIIO 
required plan sponsors to also submit detailed data for each claim in 
these reimbursement requests in order to substantiate the 
reimbursement amount plan sponsors were paid. 

[30] For information on enrollment trends in our previous report see 
[hyperlink, http://www.gao.gov/products/GAO-11-662]. 

[31] CCIIO officials explained that they initially allowed such 
documentation in an effort to increase enrollment in the federally run 
PCIP, as it was significantly lagging behind state-run PCIPs, many of 
which allowed such documentation. However, enrollment grew so quickly 
in the federally run program that CCIIO decided to reverse its 
decision in an attempt to temper enrollment growth. According to CCIIO 
guidance, children under age 19 or residents of Massachusetts or 
Vermont were excluded from the reversal. 

[32] Because Vermont already implemented many of the broader market 
reforms that will take effect through PPACA in 2014, commercial plans 
in the state already offer guaranteed coverage to individuals with 
preexisting conditions at premiums comparable to PCIP. 

[33] Spending data do not include administrative costs for HHS staff 
salaries and benefits, compliance and oversight, general information 
technology, and outreach; however, officials estimated that these 
costs were approximately $12 million for fiscal years 2011 and 2012. 
Spending data are net of any premium revenue collected from enrollees. 

[34] Data through December 2012 were the most recent available on PCIP 
administrative costs. At this time, the PCIP program had spent about 
$177 million of the $5 billion appropriation on administrative costs. 

[35] In-network services are those offered through a provider that has 
contracted with the PCIP program for reimbursement at a negotiated 
rate, while out-of-network services are those offered through a 
provider that does not have such a contract. 

[36] The enrollment suspension began on February 16, 2013, for the 
federally run PCIP and was required to begin on March 2, 2013, for 
state-run PCIPs; however, state-run PCIPs were allowed to discontinue 
enrollment prior to March 2, 2013, should they decide to do so. 

The suspension will not apply to current enrollees who move to a 
different state and would like to reenroll in PCIP within 6 months. 

[37] According to CCIIO officials, while they are not maintaining a 
wait list, they are keeping any applications they receive on file in 
the event that PCIP enrollment is reinstated. 

[End of section] 

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