CMS Issues Final Program Integrity Rule for Affordable Insurance Exchanges


On August 30, 2013, CMS published a final rule establishing certain program integrity requirements for the private health insurance marketplaces—called Affordable Insurance Exchanges (or Health Insurance Marketplaces)—established by the Affordable Care Act.  The final rule generally remains unchanged from the proposed rules published in June.  Only those rules needed to begin open enrollment in the Exchanges beginning October 1, 2013, however, have been finalized.  Other provisions not needed by October 1, 2013 will be finalized at a later date. 

Among other things, the final rule provides standards addressing:

  • Oversight and accountability for entities responsible for certain operations of the Exchanges.  These standards apply to States, in their roles of establishing and operating Exchanges and Small Business Health Options Programs (SHOPs), Federally-Facilitated Exchanges (FFEs), Federally-Facilitated Small Business Health Options Programs (FF-SHOPs), issuers of Qualified Health Plans (QHPs), Exchange appeals entities, and insurance agents and brokers.
  • An appeals process for individual eligibility determinations, employer appeals and SHOP appeals.
  • Privacy and security of personally identifiable information.
  • Increased access to customer assistance and consumer protection, and information about coverage options.
  • Registration and training for issuer applicant assisters, and brokers and agents who assist consumers.  The final rule also sets forth the standards under which HHS can terminate relationships with agents and brokers in an FFE, and includes additional standards for Web-brokers. 
  • State operations of a SHOP while HHS operates an FFE in the same State.

The rule is effective on September 30, 2013, 30 days from publication in the Federal Register.  The final rule, as published in the Federal Register, is available here.

Reporter, Tracy Weir, Washington, D.C., +1 202 626 2923,

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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