Compliance and Enforcement
Ensuring Compliance with the Health Insurance Market Reforms
Title XXVII of the Public Health Service Act (PHS Act) contemplates that states will exercise primary enforcement authority over health insurance issuers in the group and individual markets to ensure compliance with health insurance market reforms. In the event that a state notifies the Centers for Medicare & Medicaid Services (CMS) that it does not have statutory authority to enforce or that it is not otherwise enforcing one or more of the provisions of title XXVII, or if CMS determines that the state is not substantially enforcing the requirements, CMS has the responsibility to enforce these provisions in the state. This enforcement framework, in place since 1996, ensures that consumers in all states have protections of the Affordable Care Act and other parts of the PHS Act.
States and CMS have worked closely to ensure compliance with the health insurance accountability and consumer protections in federal law. The vast majority of states are enforcing the Affordable Care Act health insurance market reforms. Some states lack the authority, the ability to enforce these provisions, or both. CMS has responsibility for enforcing these requirements in a state that is not enforcing the health insurance market reforms either through a collaborative arrangement with the state or by direct enforcement to ensure all residents of the state receive the protections of the Affordable Care Act.
CMS will form a collaborative arrangement with any state that is willing and able to perform regulatory functions but lacks enforcement authority. To the extent that CMS and a state agree on a collaborative approach, the state will perform the same regulatory functions with respect to the Affordable Care Act market reform provisions as it does to ensure compliance with state law, and will seek to achieve voluntary compliance from issuers if the state finds a potential violation. Similarly, consumers will continue to contact the state for inquiries and complaints relating to the health insurance market reform requirements. Under this collaborative approach, if the state finds a potential violation and is unable to obtain voluntary compliance from an issuer, it will refer the matter to CMS for possible enforcement action.
If a state informs CMS that it does not have authority to enforce one or more of the provisions of the Affordable Care Act, and the state has not entered into a collaborative arrangement, CMS has the responsibility to directly enforce the relevant provisions in the state with respect to health insurance issuers in the group and individual markets. To do so, CMS will notify issuers in the state that they must submit policy forms to CMS for review. After collection and review of policy forms for compliance with the respective market reform provisions, CMS will notify issuers of any concerns. CMS will also conduct targeted market conduct examinations, as necessary, and respond to consumer inquiries and complaints to ensure compliance with the health insurance market reform standards. CMS will work cooperatively with the state to address any concerns.
At any time, a state that is willing and able may assume enforcement authority of the Affordable Care Act market reform standards. When that happens, CMS will work with the state to ensure an effective transition.
- Federal Market Conduct Examination (Oversight Group) Checklist (PDF) (updated 04/03/2015)
Federal Market Conduct Examination Final Reports
Current Status (as of April 8, 2016)
The following states have notified CMS that they do not have the authority to enforce or are not otherwise enforcing the Affordable Care Act market reform provisions.
Policy Form Review
Policy form review is one of the compliance tools used to confirm health insurance issuers' compliance with the provisions of the health insurance market reforms of the Affordable Care Act. Issuers required to submit form filings to CMS will need to follow instructions posted under Training Resources below.
Health Insurance and Consumer Protections Grants
Many of the market reforms and consumer protections in Part A of title XXVII of the PHS Act are new provisions that became effective for plan years beginning in 2014. The Health Insurance Enforcement and Consumer Protections Grants will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal requirements and that States are able to effectively oversee and enforce these provisions. The Health Insurance Enforcement and Consumer Protections Grant program will provide $25.5 million in grant funds to assist States in implementing and/or planning the following provisions of Part A of Title XXVII of the Public Health Service (PHS) Act:
- Section 2707 - Non-discrimination under Comprehensive Health Insurance Coverage (Essential Health Benefits Package)
- Section 2713 - Coverage of Preventive Health Services
- Section 2718 - Bringing down the Cost of Health Care Coverage (MLR)
- Section 2719 - Appeals Process
- Section 2726 - Parity in Mental Health and Substance Use Disorder Benefits
- Health Insurance and Consumer Protections Grant Fact Sheet (PDF)
- Health Insurance and Consumer Protections Grant Map: State-by-State Summary of Health Insurance and Consumer Protections Grants
State Flexibility to Stabilize the Market Grants
Many of the market reforms and consumer protections in Part A of title XXVII of the PHS Act are new provisions that became effective for plan years beginning in 2014. The State Flexibility to Stabilize the Market Grant Program (State Flexibility Grants) will provide a funding source to enhance the role of States in planning and implementing several of the Federal market reforms and consumer protections. State Flexibility Grants will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal requirements, and enhance the States’ ability to effectively regulate their respective health insurance markets through innovative measures that support the pre-selected market reforms and consumer protections under Part A of Title XXVII of the Public Health Service (PHS Act). The State Flexibility Grant program will provide $8.6 million in grant funds to assist States in implementing and/or planning the following provisions of Part A of Title XXVII of the PHS Act:
- Section 2702 – Guaranteed Availability of Coverage
- Section 2703 – Guaranteed Renewability of Coverage
- Section 2707 – Non-discrimination under Comprehensive Health Insurance Coverage (Essential Health Benefits Package)
- March 5, 2020 Information Related to COVID–19 Individual and Small Group Market Insurance Coverage
- March 12, 2020 FAQs on Essential Health Benefits Coverage and the Coronavirus (COVID-19)
- March 18, 2020 FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 FAQs on Availability and Usage of Telehealth Services through Private Health Insurance Coverage in Response to Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency
- March 24, 2020 FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering Health Insurance Coverage in the Individual and Small Group Markets
- April 11, 2020 FAQs about Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act Implementation
*This document was updated on April 15, 2020, to correct an error in footnote 10 regarding the current end date of the public health emergency related to COVID 19.
- April 13, 2020 Postponement of 2019 Benefit Year HHS-operated Risk Adjustment Data Validation (HHS-RADV)