The Centers for Medicare & Medicaid Services published a proposed rule Wednesday that establishes financial integrity standards to oversee qualified health plans (QHPs) offered in health insurance exchanges and for states around their operation of risk adjustment and reinsurance programs under the Affordable Care Act.
The agency proposes standards for special enrollment periods, for vendors that may conduct enrollee satisfaction surveys on behalf of insurers on the exchanges, for the handling of consumer complaints by plans, and for insurer participation in small business health options program (SHOP) in the regulation published in the Federal Register. The public may comment on it until July 19.
CMS also added standards around geographic rating areas and guaranteed availability and renewability and others aimed at agents and brokers for financial integrity and protections against fraud and abuse.
Starting Oct. 1, individuals and small employers will be able to enroll for coverage through the health insurance exchanges or marketplaces to start as soon as Jan. 1, 2014. The Health and Human Services secretary may enforce the exchange standards through fines.
"Most of the proposed standards are based on existing standards currently in effect in the private market, were previously proposed through the blueprint process, discussed in agency-issued sub-regulatory guidance…," the proposed rule said.
CMS also asked for feedback on how to "minimize burden" in putting the proposed policies into effect.
CMS said it encourages flexibility in the program integrity standards when states establish an exchange and SHOP programs to help employers enroll their employees in health plans.
The proposed rule also tweaks some existing language in regulations pertaining to health insurance exchanges and aligning definitions.
Among its provisions, the rule would require:
• States to keep an accurate accounting of risk adjustment or reinsurance programs and submit to HHS and make public reports on those operations. Risk adjustment and reinsurance programs help to level the playing field and stabilize premiums, but it is important to assure the soundness and transparency of the programs.
• Timeframes for refunds to enrollees and providers when an issuer incorrectly applies the advance payment of the premium tax credit or cost-sharing reductions, along with oversight and annual reporting of these records.
• Oversight of health insurers in federally-facilitated exchange according to exchange standards while also preserving states' traditional role over the insurance market.
• Monitoring, reporting and oversight of financial and exchange activities to assure that consumers receive their choice of coverage and receive advance payments of premium tax credits or cost-sharing reduction if eligible.