Program Integrity Proposed Rule
Exchanges, SHOP, Premium Stabilization Programs, and Market Standards: Safeguarding Federal Funds and Furthering Consumer Protection
On June 14, 2013, HHS released a Notice of Proposed Rulemaking - Opens in a new window (NPRM) that proposes a number of policies related to the implementation of the Affordable Care Act, including provisions regarding Affordable Insurance Exchanges, also known as Health Insurance Marketplaces. Much of the proposed rule focuses on program integrity regarding State Marketplaces, issuers offering coverage in the Federally-facilitated Marketplace, advance payments of the premium tax credit and cost-sharing reductions, and premium stabilization programs. The overarching goal of the proposed provisions is to safeguard federal funds and to protect consumers by ensuring that issuers, Marketplaces, and other entities comply with federal standards meant to ensure consumers have access to quality, affordable health insurance.
This rule also proposes establishing standards for HHS-approved enrollee satisfaction survey vendors, standards for the handling of consumer complaints by issuers in the Marketplace, and other provisions meant to ensure smooth operation of the Marketplaces, protect consumers, and give flexibility to states.
Key policies in the proposed rule include:
Oversight of State-Operated Premium Stabilization Programs
Risk adjustment and reinsurance programs are important elements in guaranteeing affordable health insurance to consumers by helping to ensure a level playing field and stabilization of premiums. To protect the financial integrity of these programs, HHS proposes standards for the oversight of states that operate either risk adjustment or reinsurance programs. The rule would require that states keep an accurate accounting for the programs, submit to HHS and make public reports on operations, and take other steps to ensure the soundness and transparency of the programs.
Program Integrity for Advance Payments of the Premium Tax Credit and Cost-sharing Reductions
One of HHS’s key goals with respect to the oversight of advance payments of the premium tax credit and cost-sharing reductions is ensuring that eligible enrollees receive the correct tax credit and/or cost sharing reduction. In order to achieve this goal, HHS proposes timeframes for refunds to eligible enrollees and providers, as applicable, when an issuer incorrectly applies the advance payment of the premium tax credit or cost-sharing reductions, or incorrectly assigns an individual to a plan variation (or a standard plan without cost-sharing reductions). HHS also proposes general standards necessary for the oversight of these payments, including the maintenance of records, annual reporting of summary level statistics, and audits.
Program Integrity of State Marketplaces
Effective and efficient oversight of state-based Marketplaces will help ensure that affordable and quality health coverage is available to all Americans. This rulemaking proposes standards for the oversight of State Marketplaces through monitoring, reporting, and oversight of financial activities and Marketplace activities. These mechanisms would assure that consumers are properly given their choices of coverage available, that consumers correctly receive advance payments of the premium tax credit or cost-sharing reductions if they qualify, and that Marketplaces are meeting the standards of the Affordable Care Act in a transparent manner.
Oversight of QHP Issuers in Federally-facilitated Marketplaces
To protect consumers and the financial integrity of Federally-facilitated Marketplaces, HHS proposes standards that would establish a progressive approach for the oversight of health insurance issuers. This includes HHS focusing on ensuring compliance with Marketplace-related standards while preserving states’ traditional role in overseeing the general insurance market.
Flexibility for States
HHS is proposing additional state flexibility by permitting a state to operate a State-based Small Business Health Options Program (SHOP) while HHS would operate an individual market Federally-facilitated Marketplace in that state. These provisions have been developed based on state feedback and would allow a state to focus on the effective implementation of the SHOP.
Consumer Protections for Enrollment Assistance
Agents and brokers will play an important role in helping consumers and small businesses shop for and compare coverage in the Marketplaces. This rule proposes to build on existing standards for agents and brokers by clarifying the pathways through which agents and brokers will help consumers and small businesses in Federally-facilitated Marketplaces.
Establishment of Standards for HHS-approved Enrollee Satisfaction Survey Vendors
The Affordable Care Act provides for the development of an enrollee satisfaction survey that will be available to the public and will allow for the easy comparison of enrollee satisfaction levels among comparable plans in the Marketplace. This rule sets forth a process for approving and overseeing survey vendors to administer the survey on behalf of QHP issuers in the Marketplace.
Public comments are invited on the Program Implementation: Exchanges, SHOP, Risk Adjustment, Reinsurance, and Market Rules NPRM using the process set forth in the NPRM - Opens in a new window .
- 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)