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Report (OEI-01-12-00290)

06-16-2013
Early Implementation of the Consumer Operated and Oriented Plan Loan Program

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Summary

WHY WE DID THIS STUDY

The Patient Protection and Affordable Care Act established a loan program to foster the creation of nonprofit, consumer-governed health insurance issuers called CO OPs that will offer qualified health plans in the individual and small group markets. Goals of the CO-OP program include promoting integrated care, quality, and efficiency. As of January 2, 2013, the Centers for Medicare & Medicaid Services (CMS) had awarded loans totaling $1.98 billion to 24 CO-OPs. The applicants that receive this funding are new entities that may face financial and operational challenges in a competitive insurance market. CMS manages the CO-OP program and must implement it in a short time so that CO-OPs will be ready to enter the market of Affordable Insurance Exchanges-i.e., competitive marketplaces for health insurance.

HOW WE DID THIS STUDY

We reviewed applications from the first 18 CO-OPs that were awarded funding. We interviewed senior staff from these CO-OPs to describe how CO-OPs plan to meet program requirements and goals, such as consumer governance, integrated care, and increased quality. We also interviewed CMS staff and reviewed CMS's documentation related to oversight of the 18 CO-OPs to assess their progress during the startup phase and assess CMS's oversight of the CO-OP program.

WHAT WE FOUND

In their applications, CO-OPs broadly described various ways to meet program requirements related to consumer governance. CO-OP applications identified primary care, electronic health data, and outsourcing as the main mechanisms for achieving integrated care at lower costs while improving quality. Despite challenges, CO-OPs have made progress toward achieving licensure and met 90 percent of their milestones during the period of our review from February through September 2012. CMS's oversight strategy includes frequent monitoring and early intervention to ensure that CO-OPs adhere to program requirements and goals.

WHAT WE CONCLUDE

Although CO-OPs appear to be making progress, at the time of our review they were still hiring staff, obtaining licensure, and building necessary infrastructure. In addition, the extent to which any particular CO-OP can achieve program goals depends on a number of unpredictable factors, such as each State's Exchange operations, market competition, and enrollment.

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