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CMS releases proposed rule to improve the integrity of the Exchange

CMS releases proposed rule to improve the integrity of the Exchange
Proposed rule advocates for additional oversight to protect both the issuer and consumer

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule, “Patient Protection and Affordable Care Act (PPACA): Exchange Program Integrity.”  This proposal would safeguard taxpayer dollars by ensuring that people are accurately determined eligible for premium subsidies they receive through the Exchange.  In addition, to better align federal regulations with statutory requirements and congressional intent, the rule proposes that issuers must send a separate bill and collect separate payments for the portion of the consumer’s premium attributable to certain abortion services for which public funding is prohibited. 

“This administration is committed to making sure taxpayer dollars are spent appropriately,” said CMS Administrator Seema Verma.  “Maintaining a high level of program integrity on the Exchange is essential, including ensuring that premium tax credits only go to those who are eligible for them. This proposed rule represents CMS’ commitment, consistent with the law, to continuously improve and strengthen oversight over the programs we administer on behalf of the American taxpayer.”

The proposed rule would address several recommendations based on audits of both State and Federal Exchanges by the Office of Inspector General (OIG) and the Government Accountability Office (GAO) identifying substantial weaknesses in the process for determining eligibility for advance payments of the premium tax credit (APTCs) and cost-sharing reductions (CSRs).

With this proposal CMS is demonstrating its commitment to protecting the consumer and the integrity of the Exchange by ensuring the correct people are being identified as eligible for subsidies.  CMS recently took action to review the eligibility determination processes used by state Medicaid programs and we are now working to address the integrity of the Exchange eligibility determination process.

In this rule, CMS proposes a number of new initiatives that would place additional safeguards on the eligibility and enrollment process across all platforms, including State-based Exchanges (SBEs), State-based Exchanges using the Federal Platform (SBE-FPs), and Federally-facilitated Exchanges (FFEs).  For example, CMS is proposing to strengthen programmatic oversight of SBE program reporting requirements to ensure they are correctly identifying eligible enrollees, including those who are qualified for APTCs and CSRs.  Under this proposal, SBEs will not only have to provide annual reports showing their compliance, but they will also have to demonstrate their compliance around eligibility and enrollment processes through various auditing vehicles.

This proposed rule also includes ways to safeguard taxpayer funds through improvements to our data matching processes to ensure people are enrolled in the most appropriate type of coverage for them.  We propose revisions to the periodic data matching (PDM) requirements that would allow CMS to identify and resolve issues related to consumers who are dually enrolled in both Medicare and a Qualified Health Plan (QHP) through the Exchange more frequently.  If finalized, beginning with plan year 2020, CMS would require the Exchange to conduct Medicare, Medicaid/CHIP, and as applicable, Basic Health Plan (BHP) PDM at least twice a year for QHP enrollees who receive subsidies.

Lastly, CMS will continue its effort to enforce requirements in section 1303 of the PPACA, which outlines specific requirements for issuers that offer coverage for certain abortion services that are prohibited from receiving federal funds, including that issuers must collect a “separate payment” from each enrollee for the portion of the consumer’s premium attributable to these services.

In an October 2017 bulletin, CMS informed stakeholders that, beginning with the 2018 plan year, we intended to fully enforce the requirements to comply with section 1303 of PPACA, and clearly outlined the statutory requirements for separate payment and the prohibition on the use of  federal funds for certain abortion services as well as the steps required to segregate funds for non-Hyde abortion services.  In the bulletin, CMS indicated further action would be taken to ensure compliance with the requirements of section 1303 and its implementing regulations. As a result, the proposed rule would also add new compliance reviews to monitor FFE issuer compliance with the requirements applicable to issuers offering coverage for certain abortion services that are prohibited from receiving federal funds.

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To view the proposed rule, please visit:


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