[author: Taylor Whitten]
On November 9, 2018, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule (the Proposed Rule) that would modify the oversight standards of exchanges established under the Affordable Care Act (Exchanges) that were established by states, update periodic data matching frequency and authority criteria, and change the process for verifying consumer tax information. In addition, under the Proposed Rule, certain issuers would have to follow new standards for collecting the premium portion attributable to abortion services’ coverage as a separate transaction from collection of payment for other services. Comments are due on or before December 14, 2018.
According to CMS, the proposed oversight measures are aimed at ensuring that individuals who enroll in qualified health plans (QHPs) through individual market exchanges receive the correct amount of advanced payments of premium tax credits (APTCs) and cost-sharing reductions (CSRs) that decrease individuals’ out-of-pocket payment for healthcare expenses. To achieve these goals, the Proposed Rule adds: (i) requirements that the Exchanges conduct periodic data matching twice a year to identify individuals that are dually enrolled in Medicare and Qualified Health Plans (QHPs); (ii) opt-in authorizations in the enrollment application permitting access to Medicare enrollment information and voluntary termination of dually-enrolled QHP coverage; (iii) new details about the reporting requirements for State-based Exchanges (SBEs) and State-based Exchanges on the Federal Platform (SBE-FPs); and (iv) clarification about the SBEs and SBE-FPs annual audit reporting requirements.
Lastly, the Proposed Rule adds measures to enforce the prohibition of using certain public funds to pay for abortion services. Under the Hyde Amendment, federal funds may only be used to pay for abortion services when a woman suffers from a life-threatening physical disorder, physical illness, or physical injury that would place the woman in danger of death unless an abortion is performed (Hyde abortion coverage). If an issuer elects to cover non-Hyde abortion services under a QHP sold through an individual market Exchange, the issuer must ensure that no public funds are used to pay for the abortion services. The issuer must collect a separate payment from the enrollee for an amount equal to the greater of the actuarial value of coverage for abortions or one dollar per enrollee per month. The Proposed Rule would include a system change that would ensure that the minimum premium amount of one dollar per month per enrollee would be assigned to all enrollments into plans offering non-Hyde abortion coverage so that the issuers may collect this amount directly from consumers receiving non-Hyde abortion services.
According to CMS, the Proposed Rule is a continuation of the Administration’s efforts to increase Exchange oversight, strengthen program integrity, and combat fraud. CMS has recently implemented other rules related to program integrity including new pre-enrollment verification requirements and other mechanisms that verify enrollee eligibility for APTC and CSR amounts.
To view CMS’s fact sheet, click here. To view the Proposed Rule available in the Federal Register, click here.
