CHA News Article

CMS Issues Program Integrity Final Rule
Rule finalizes policies designed to protect consumer information and ensure appropriate use of federal funds

Last week, the Centers for Medicare & Medicaid Services (CMS) issued the attached rule finalizing policies from its proposed rule titled “Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards,” published June 19. The rule also finalizes eligibility and Small Business Health Options Program (SHOP) appeals provisions from the proposed rule titled “Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Procedures for Medicaid and Exchange Eligibility Appeals,” published January 22. 

In the rule, CMS outlines exchange standards for eligibility appeals, verification of eligibility for minimum essential coverage, and treatment of incomplete applications. It also establishes additional consumer protections regarding privacy and security; clarifies the role of agents, brokers and issuer application assisters in helping consumers obtain exchange coverage; provides for the handling of consumer cases; and establishes non-discrimination standards for methods of premium payment. The final rule also sets forth standards with respect to a state’s operation of a SHOP. Although many of the provisions in the final rule will become effective by Oct. 1, CMS does not believe that affected parties will have difficulty complying with the provisions by their effective dates because the standards are based on standards currently in effect in the private health insurance market. In addition, CMS notes that the standards were previously addressed in the exchange blueprint process, discussed in agency-issued sub-regulatory guidance, or discussed in the preambles to the Exchange Establishment Rule, Premium Stabilization Rule, or the U.S. Department of Health and Human Services’ Notice of Benefit and Payment Parameters for 2014.

The Center for Consumer Information and Insurance Oversight (CCIIO) within CMS has also released a fact sheet that outlines the key provisions discussed in the final rule.