CHA News Article

HHS Releases Final Program Integrity Rule Related to ACA and Exchanges

Last week, the U.S. Department of Health and Human Services (HHS) released the attached rule finalizing parts of the Affordable Care Act (ACA), including provisions regarding marketplaces (exchanges). The rule outlines program integrity standards for advance payments of the premium tax credit, cost-sharing reductions, premium stabilization programs, and state marketplaces, as well as oversight of insurers offering coverage in the federally facilitated marketplaces and standards for HHS-approved enrollee satisfaction survey vendors. 

The rule also amends standards and finalizes interim provisions set forth in the interim final rule, related to risk corridor calculations and cost-sharing reduction reconciliation. The final rule is largely unchanged from previous proposed rules and guidance, and is intended 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.”

Key provisions of the final rule include:

  • Oversight of State-Operated Premium Stabilization Programs – The final rule establishes standards for the oversight of states that operate 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 - In order to ensure that eligible enrollees receive the correct tax credit and cost-sharing reductions, HHS establishes timeframes for refunds to eligible enrollees and providers when an issuer or marketplace incorrectly applies advance payments 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). The final rule includes general standards necessary for the oversight of these payments, including standards governing the maintenance of records, annual reporting of summary statistics, and audits.
  • Program Integrity of State Marketplaces – The final rule establishes standards for the oversight of state marketplaces through monitoring, reporting and oversight of financial activities and marketplace activities. These mechanisms help to ensure that consumers are properly given their choices of available coverage, that consumers receive the full amount of advance payments of the premium tax credit and cost-sharing reductions for which they qualify, and that marketplaces are operating transparently.
  • Oversight of Qualified Health Plan (QHP) Issuers in Federally Facilitated Marketplaces – The final rule provides for the oversight of health insurance issuers operating in marketplaces by including requirements, such as the maintenance of records requirement and participation in investigations and compliance reviews.  
  • 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. The final rule outlines the process for approving and overseeing survey vendors to administer an enrollee satisfaction survey on behalf of QHP issuers in the marketplace.
  • Finalizing Provisions of the Interim Final Rule - The final rule amends standards and adopts as final interim provisions set forth in the interim final rule, “Amendments to the HHS Notice of Benefit and Payment Parameters for 2014,” aligning risk corridors calculations with the single risk pool provision, and finalizes standards permitting issuers of QHPs to use an alternate methodology for calculating the value of cost-sharing reductions, for the purpose of reconciliation of advance payments of cost-sharing reductions.