Press release

CMS Announces Enhanced Program Integrity Efforts for the Exchange

CMS Announces Enhanced Program Integrity Efforts for the Exchange
Rule provides additional protection for Americans by ensuring effective Exchange oversight and accurate eligibility determinations for premium subsidies

The Centers for Medicare & Medicaid Services (CMS) issued the Exchange Program Integrity Final Rule, today, that implements policies aimed at protecting taxpayer dollars by ensuring that Exchange enrollees are accurately determined eligible for premium subsidies.

The final rule focuses on strengthening oversight of State-based Exchanges (SBE) and  implementing a new requirement that Exchanges conduct regular eligibility verifications with outside data sources at least twice a year. In addition, the rule aligns federal regulations with the statutory requirements of the Patient Protection and Affordable Care Act (PPACA) to help ensure consumers understand the coverage they are buying and also requires Qualified Health Plan (QHP) issuers to send a separate bill and attempt to collect separate payments for the portion of consumers’ premiums attributable to certain abortion services for which public funding is prohibited.  

Our healthcare programs, including the Exchanges, are evolving rapidly, and our program integrity efforts must keep up,” said CMS Administrator Seema Verma. “Today’s final rule drastically improves our ability to pay it right—to make the right payment to the right plan for the right people. The Trump Administration will spare no effort to ensure that taxpayer dollars are only going to those truly eligible.”

Today’s final rule addresses several recommendations from the Office of Inspector General (OIG) and the Government Accountability Office (GAO). Those recommendations addressed issues such as weaknesses in the process for determining eligibility for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs) in both the State and Federal Exchanges. To address this issue, the rule strengthens programmatic oversight of SBE program reporting requirements to confirm states are correctly identifying eligible enrollees, including those who are qualified for APTC and CSRs.

Specifically, SBEs are required to conduct and submit the results of annual programmatic audits and CMS is finalizing changes that clarify the scope of such audits, including procedures to test eligibility and enrollment transactions to ensure SBEs that operate their own eligibility and enrollment platforms are properly determining consumer eligibility for QHPs, APTC and CSRs. These changes will strengthen CMS’s programmatic oversight and the program integrity of SBEs, and better align with CMS’s program integrity priorities, providing CMS and states with greater insight into SBE compliance with eligibility and enrollment standards in a more cost-effective manner.

The rule also implements safeguards regarding the eligibility and enrollment process across all Exchanges, including SBEs, State-based Exchanges on the Federal Platform (SBE-FPs), and Federally-facilitated Exchanges (FFEs). This includes enhanced periodic data matching that will allow CMS to more frequently identify and resolve issues related to consumers who are dually enrolled in both Medicare and a QHP through the Exchange. This will ensure that people are enrolled in the most appropriate type of coverage for them. Beginning with plan year 2020, CMS will require SBEs to conduct Medicare, Medicaid/CHIP, and as applicable, Basic Health Plan periodic data matching at least twice a year for QHP enrollees who receive subsidies.

Through the SBE oversight requirements and improved data verification and audit requirements, CMS will be able to identify and correct eligibility and enrollment issues sooner. Early identification of eligibility and enrollment issues is particularly important for consumers who are eligible for or enrolled in other coverage because it can minimize the time these consumers inadvertently receive tax credits that they will have to pay back later, and mitigate risks that they are paying premiums for a plan they no longer need.

The rule includes new requirements to align federal regulations with the statutory requirements of section 1303 of the Affordable Care Act, which prohibits federal funding for coverage of certain abortion services (“non-Hyde abortion services”). Section 1303 specifically prohibits QHPs from using APTC or CSRs to pay coverage of for abortions for which public funding is prohibited.  We estimate that 18 states currently have QHP issuers that offer coverage of non-Hyde abortion services. Section 1303 requires these QHP issuers to collect a separate payment from each enrollee for the portion of the consumer’s premium attributable to health insurance coverage of these services.

The rule better aligns with Congress’ intent for QHP issuers to collect two distinct payments, one for the coverage of non-Hyde abortion services, and one for coverage of all other services covered under a QHP. Pursuant to the law, this rule will ensure that taxpayers do not contribute funds to pay for coverage of abortion services for which funding isn’t allowed by law, and will alert consumers that their health plan covers abortion services, allowing them to make fully informed decisions about their coverage.

The separate billing requirements in the final rule become effective June 27, 2020; the balance of the final rule becomes effective nationwide within 60 days from today.

To view the fact sheet, please visit:

The final rule (CMS-9922-F), can be viewed here:


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