Compliance, Certification, and Penalties

The Administrative Simplification provisions in ACA require health plans to file a statement with HHS certifying that their data and information systems are in compliance with the standards and operating rules. The certification schedule is as follows:

by December 31, 2013 for standards and applicable operating rules:
• eligibility for a health plan
• health claim status
• electronic funds transfers (EFT)
• health care payment and remittance advice (ERA)

and by December 31, 2015 for standards and applicable operating rules:
• health claims or equivalent encounter information
• health plan enrollment/disenrollment
• health plan premium payment
• referral certification and authorization transactions
• health care claims attachments.

Requirements for certification will be provided during the rule making process.  Substantial financial penalties for failures to certify were established in the law.  Penalties for non compliance were formalized in the original HIPAA legislation and updated by the HITECH rules in 2009.

The Secretary is directed to periodically audit health plans to assess compliance with standards and operating rules. Details about the audit program will be forthcoming in the compliance certification final rule.

For additional information on the Affordable Care Act Administrative Simplification, please go to the “Related Links Outside CMS” section below.