Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs;…
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Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges
Final rule.
CFR Part: "45 CFR Parts 146, 147, 148, 155, and 156"
RIN Number: "RIN 0938-AS32"
Citation: "79 FR 52994"
Document Number: "CMS-9941-F"
Page Number: "52994"
"Rules and Regulations"
SUMMARY: This final rule specifies additional options for annual eligibility redeterminations and renewal and re-enrollment notice requirements for qualified health plans offered through the Exchange, beginning with annual redeterminations for coverage for benefit year 2015. This final rule provides additional flexibility for Exchanges, including the ability to propose unique approaches that meet the specific needs of their state, while streamlining the consumer experience.
DATES: These regulations are effective on
FOR FURTHER INFORMATION CONTACT:
SUPPLEMENTARY INFORMATION: This
Table of Contents
I. Background
A. Legislative Overview
B. Stakeholder Consultation and Input
C. Structure of the Final Rule
II. Provisions of the Proposed Regulations and Analysis and Responses to Public Comments
A. Part 146--Requirements for the Group Health Insurance Market; Subpart E--Provisions Applicable to Only Health Insurance Issuers
B. Part 147--Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets
C. Part 148--Requirements for the Individual Health Insurance Market; Subpart B--Requirements Relating to Access and Renewability of Coverage
D. Part 155--Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act; Subpart D--Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
E. Part 156--Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges; Subpart M--Qualified Health Plan Issuer Responsibilities
III. Collection of Information Requirements
IV. Regulatory Impact Statement
I. Background
A. Legislative Overview
The Patient Protection and Affordable Care Act (Pub. L. 111-148) was enacted on
Starting on
Section 1411(f)(1)(B) of the Affordable Care Act directs the Secretary of
B. Stakeholder Consultation and Input
The Department of
C. Structure of the Final Rule
The regulations in this final rule will be codified in 45 CFR parts 146, 147, 148, 155, and 156. Part 146 specifies standards related to the group health insurance market, including guaranteed renewability of coverage for employers in the group market. Part 147 specifies standards related to health insurance reforms for the group and individual health insurance markets, including guaranteed renewability of coverage. Part 148 specifies standards for the individual health insurance market, including guaranteed renewability of individual health insurance coverage. Part 155 specifies standards related to the establishment, operation, and minimum functionality of Exchanges, including annual eligibility redeterminations. Part 156 specifies standards for health insurance issuers with respect to participation in an Exchange.
II. Provisions of the Proposed Regulations and Analysis and Responses to Comments
On
In this final rule, we provide a summary of each proposed provision, a summary of and responses to public comments received, and the provisions we are finalizing.
A. Part 146--Requirements for the Group Health Insurance Market; Subpart E--Provisions Applicable to Only Health Insurance Issuers
For a discussion of the provisions of this final rule related to Part 146, see section II.B of this preamble.
B. Part 147--Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets
In the preamble to the
In this final rule, we amend the guaranteed renewability regulations at
Final Rule Action: We are amending the guaranteed renewability regulations at
C. Part 148--Requirements for the Individual Health Insurance Market; Subpart B--Requirements Relating to Access and Renewability of Coverage
For a discussion of the provisions of this final rule related to Part 148, see section II.B of this preamble.
D. Part 155--Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act; Subpart D--Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
In SEC 155.330, we proposed to amend paragraph (b)(4), which addresses reporting changes in the context of eligibility redeterminations during a benefit year. Our proposal provided that the Exchange must allow an enrollee, or an application filer on behalf of the enrollee, to report changes via the channels available for the submission of an application; however, we proposed that the Exchange be permitted, but not required, to allow an enrollee, or an application filer, on behalf of the enrollee, to report changes via mail. We noted that experience has shown that eligibility changes reported by mail are often difficult to process because they frequently trigger telephone contact to gather additional information needed to process the change. We noted that, if finalized, we anticipate that the FFE would not accept changes reported via mail for the foreseeable future.
Comment: We received several comments on the proposed changes to
Response: We are finalizing the provision as proposed, permitting Exchanges flexibility to determine whether to provide a process to report changes via mail and note that the FFE will be using this flexibility to not provide such a process via mail. We agree that vulnerable populations must have ready access to the Exchange to report changes. However, as noted in the preamble to the proposed rule, experience has shown that changes reported via mail often require significant follow-up and can result in delays in processing pertinent eligibility information, often to the detriment of the consumer. Accordingly, while Exchanges may allow for the reporting of changes by mail, they are not required to do so. The FFE will elect not to allow changes by mail for the foreseeable future.
Comment: One commenter asked whether the call center would be able to inform the individual the result of reporting a change. Another commenter questioned whether the Exchange would provide written confirmation, including an explanation of any action taken, to the enrollee who submits a change.
Response: In the FFE, we anticipate that the majority of enrollees will know the outcome of the changes reported through the call center during their call. As with all actions that result in a new eligibility determination, the enrollees will receive an eligibility determination notice (in the format--hard copy or electronic--that they have chosen).
Final Rule Action: We are finalizing the provision as proposed in
In SEC 155.335(a), we proposed amendments to the general requirement for annual eligibility redetermination. Specifically, we proposed in paragraph (a)(1) that, except as specified in paragraphs (l) and (m) of this section, the Exchange must redetermine the eligibility of a qualified individual on an annual basis. In paragraph (a)(2), we proposed the Exchange must conduct annual redeterminations using one of three options: (1) The procedures described in
Comment: We received many comments supporting the flexibility provided by the three options for Exchanges to implement annual redetermination procedures. These commenters believed that the proposal would promote uninterrupted coverage for enrollees, as well as enhance and streamline the redetermination process.
Response: We appreciate the support for the three options we proposed for Exchanges to conduct annual eligibility redeterminations.
Comment: A few commenters supported moving Exchanges toward a single standard for annual eligibility redeterminations, primarily in accordance with
Response: We anticipate that the flexibility offered to Exchanges to select procedures for conducting annual redeterminations will encourage innovation and best practices that will benefit both Exchanges and stakeholders over time. We caution that no matter which option an Exchange implements for annual redeterminations, the Exchange will be held to applicable program integrity and oversight standards to ensure an effective process.
Comment: Several commenters asked that a fully-automated redetermination process be implemented. Specifically, these commenters recommended that enrollees not be required to reapply at their Exchange in order to maintain accurate subsidies and program eligibility by the 2016 benefit year. In contrast, one commenter requested that auto-redeterminations not be implemented until 2016.
Response: We recognize the importance of a simple consumer experience during the eligibility redetermination and re-enrollment process as well as the potential benefits consumers may receive by regularly updating their application information, or simply confirming its accuracy.
Comment: We received a few comments from the issuer community citing concern that the guidance released alongside the proposed rule, specifying the alternative procedures that the FFE would use under proposed
FOOTNOTE 1 Guidance on Annual Redeterminations for Coverage for 2015, available at http://www.coms.gov/cciio/resources/Regulations-and-Guidance/index.html. END FOOTNOTE
Response: We indicated in the
Comment: Commenters, particularly State-based Exchanges, were supportive of the option proposed in
Response: Although we understand the desire to create uniform processes across Exchanges by permitting this flexibility, Exchanges will be able to benefit from the experiences of one another and be able to apply lessons-learned to improve their consumers' redetermination experience.
Comment: We received a few comments regarding how HHS should conduct reviews of alternative procedures proposed by Exchanges. One commenter requested that reviews of alternative procedures be conducted on an individualized basis, considering state-specific factors, including operational structure, 2014 experience, and information technology capabilities. Similarly, several commenters recommended specifying additional standards that Exchanges' alternative procedures must meet as part of the review process. Other commenters recommended that alternative procedures must meet minimum federal standards, not be burdensome for consumers, and be clear improvements from the process implemented by the FFE. Finally, a commenter requested that alternative procedures for redeterminations be publicly available.
Response: We appreciate the many suggestions for standards for alternative redetermination procedures under
Comment: Several commenters submitted comments regarding the substance of the Guidance on Annual Redeterminations for 2015 released contemporaneously with the
Response: The substance of the Guidance on Annual Redeterminations for 2015 is beyond the scope of the proposed rule and these comments are not addressed in this final rule.
Final Rule Action: We are finalizing
In SEC 155.335(e), we proposed to revise the language regarding change reporting to generally align with the standards in
Comment: We received some comments regarding the proposed provisions in paragraph (e). A few commenters recommended not revising the provisions in paragraph (e) at all. Other commenters sought clarification as to whether the changes reported at annual redetermination should be based on current circumstances or could be based on expected changes in the coming benefit year. Another commenter supported the proposed provision in paragraph (e)(1), which would not permit Exchanges to require a qualified individual who did not request an eligibility determination for insurance affordability programs to report changes that affect eligibility for insurance affordability programs. One commenter recommended that Exchanges be required to inform people about the availability of financial assistance through the Exchange even if they are not currently receiving it. Finally, one commenter requested that Exchanges be required to include a summary of the individual's application on file in the annual redetermination notice and to ensure that this information is in plain language so it is easily accessible for all consumers.
Response: We believe the amendments made to this paragraph are necessary to generally align with the standards in
Comment: Several commenters requested that paragraph (e) provide a minimum threshold below which income changes would not be required to be reported for annual redetermination. We also received a comment asking that Exchanges use consistent messaging about reporting changes in income to reduce consumer confusion.
Response: We note that the provision for reporting changes during the benefit year at
Comment: We received several comments about the requirement in proposed
Response: The requirement to report changes within 30 days is intended to ensure that eligibility determinations remain accurate in view of qualified individuals' most current eligibility information, and reduce the risk that consumers may have to repay advance payments of the premium tax credit in excess of what they are eligible for, through the reconciliation process. Individuals who report changes more than 30 days after the change will still receive an updated eligibility determination.
Comment: We received comments both supporting and opposing the proposed change in paragraph (e)(2) to eliminate the requirement for Exchanges to accept changes reported by mail, with many commenters focusing on the potential lack of access vulnerable populations may have to the methods Exchanges are required to provide for reporting changes. We also received a few general recommendations related to this provision. For example, one commenter recommended Exchanges establish tiered support through the call center. Another comment emphasized the need for a streamlined process for consumers to update their income and eligibility information without having to go through the entire application process.
Response: As noted in responses to the comments regarding the proposed changes to
Final Rule Action: We are finalizing
In SEC 155.335(j), we proposed to modify the standards for re-enrollment in coverage. First, in paragraph (j)(1), we proposed that if an enrollee remains eligible for enrollment in a QHP through the Exchange upon annual redetermination, and the product under which the QHP in which he or she was enrolled remains available for renewal, consistent with 45 CFR 147.106, such enrollee will have his or her enrollment in a QHP under the product renewed unless he or she terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP, in accordance with
Second, in paragraph (j)(2), we proposed standards to address re-enrollment in situations in which the product under which an enrollee's QHP is offered is not available through the Exchange for renewal, consistent with
Comment: One commenter noted the importance of continuity of coverage without gaps and suggested that consumers have full transparency into the process and be informed why they are being enrolled in a product and notified that some issuers who did not participate in the Exchange in the 2014 benefit year may be offering plans in the 2015 benefit year that consumers may want to consider. Similarly, a commenter did not support the re-enrollment provisions, believing they would steer members away from the shopping experience and discourage incumbent issuers from creating new and innovative products. A few commenters noted their general support for the provisions in paragraph (j) and noted that they would cause the least amount of disruption to the enrollee.
Response: We believe that the rule, as finalized, best furthers the goal of creating continuity of coverage for consumers at annual redetermination and enrollment. We agree that consumers should understand why they are being enrolled into a new plan, if applicable, and be reminded that, in all cases, after being redetermined to be eligible for coverage through the Exchange, they can return to the Exchange to shop for another plan, if they wish.
Comment: Some commenters suggested delaying the implementation of the proposed auto-enrollment policy until the 2016 benefit year due to concerns about operational readiness. A commenter asked that, if HHS did proceed with 2015 implementation, the enrollment policy be permitted only at the end of open enrollment after all enrollee outreach has been conducted.
Response: We understand that QHP issuers, Exchanges, consumers, and other stakeholders are concerned that they have time to prepare for the redetermination and enrollment period for benefit year 2015 coverage. We agree that encouraging aggressive outreach and enrollee engagement are important. However, it is important for stakeholders to have sufficient guidance to conduct redetermination and re-enrollment in accordance with federal standards during the entire open enrollment period for the 2015 benefit year. Postponing the implementation of enrollment procedures until the end of the open enrollment period could result in some consumers experiencing gaps in coverage. We believe that the Exchange should complete the redetermination and re-enrollment process early enough so that consumers have coverage (and financial assistance, if applicable) effective
Comment: A few commenters provided general comments on and alternatives to the proposed hierarchies in paragraphs (j)(1) and (2). For instance, one commenter disagreed with the use of the hierarchy because of the substantial differences in plans that a consumer may be renewed or re-enrolled into at different metal levels and in different product lines. Another commenter thought enrolling a consumer in a product or plan other than the consumer's identical QHP would cause confusion and interrupt established provider-patient care, and inflate premiums. Similarly, a few commenters requested flexibility in applying the hierarchy in cases where its application could harm consumers or where the enrollee is in a unique situation. For example, if the enrollee lives outside of the plan's service area, is enrolled in a catastrophic plan, or has aged off a parent's policy, the consumer may not have eligibility to re-enroll in the same plan.
Response: We understand the complexities that may result when consumers are placed in a different plan or product as the result of renewal or re-enrollment. However, we note that placement into another plan or product is not intended to be the usual result of the open enrollment period. The hierarchy proposed in
Comment: We received several comments regarding the issuer's role in the re-enrollment process, particularly around the determination of when a product is "most similar" to an enrollee's current product, as stated in
Response: QHP issuers are in a unique position to understand both the characteristics of enrollees' current products and the issuers' other product offerings. As part of the QHP certification process QHP issuers in the FFE will submit crosswalks, mapping similar plans and products. Mapping enrollees in a given product to a similar product is a common industry practice.
As noted earlier, a key priority during the open enrollment period is to ensure that current enrollees have continuity of coverage and do not experience a gap in that coverage or their financial assistance. QHP issuers, coordinating with Exchanges to implement the re-enrollment and renewals, can streamline the re-enrollment and renewal process because they can easily determine whether a product will be available and, if not, what product, in accordance with the hierarchy established in this rule, would cause the least amount of disruption to the enrollee for re-enrollment.
Finally, we note that a product (as defined in
Comment: A few commenters representing the issuer community submitted questions regarding the link between stand-alone dental plans and the renewal of medical coverage. For example, a commenter questioned whether there is an impact on enrollment in a stand-alone dental plan if an individual re-enrolls into a different medical plan. We received one suggestion that re-enrollment for stand-alone dental plans should emphasize maintaining the same plan type, such as high or low coverage, and design, such as family or child-only coverage.
Response: As excepted benefits, dental plans are not subject to the guaranteed renewability standards in
Nonetheless, to minimize disruptions in coverage for enrollees, in the FFE, re-enrollment for stand-alone dental plan (SADP) enrollees will follow the hierarchy in
We clarify that if an enrollee visits the FFE during the 2015 open enrollment period to change his or her QHP enrollment, he or she will need to re-select his or her SADP at the same time, because the FFE requires that QHPs and SADPs be selected at the same time. If an enrollee doesn't return to the FFE to affirmatively select plans by
Comment: A few commenters requested that HHS clarify the meaning of "a plan at the same metal level" proposed at paragraph (j)(1)(ii). One commenter suggested that this meant a plan with the same QHP issuer.
Response: We clarify that the hierarchy in
Comment: We received a few comments regarding the proposed requirement to re-enroll an enrollee in a plan that is one metal level higher or lower than the enrollee's current QHP at
A few commenters also addressed the request for comment regarding whether the hierarchy should only prioritize a plan with a lower metal level, or whether, in general, priority should be placed on plans that have a premium that is closest to the premium of the plan in which an enrollee is currently enrolled.
Response: We note that there was no consensus in favor of one approach over the other. As noted before, these provisions are not expected to be used frequently and are positioned in the hierarchy to promote less-disruptive re-enrollment scenarios first. These provisions are being finalized without substantive changes.
We also clarify, in response to the comments, that these provisions impose requirements on the Exchange because, although the QHP issuers will facilitate the enrollment by submitting plan crosswalks, the Exchange is ultimately responsible for ensuring that enrollment is effectuated according to the hierarchy. To reflect this, we are not finalizing proposed
Comment: We also received comments from tribes regarding the effects of proposed renewal and re-enrollment regulations on American Indians and Alaska Natives (AI/ANs), noting that the zero and limited cost-sharing plan variations available to AI/ANs cross the four metal levels. The commenters recommended that the regulations be revised to give QHP issuers the flexibility to keep AI/ANs in their current plan or another bronze level plan. Finally, the commenters highlighted the importance of addressing this special circumstance for AI/ANs because they should always have an alternate zero or limited cost-sharing plan at any level available to them and should never be moved to a higher level plan if their zero or limited cost-sharing plan variation is eliminated.
Response: All QHPs must offer zero and limited cost-sharing plan variations at every metal level and, thus, if a particular QHP is no longer offered, the AI/AN should be able to enroll in another zero or limited cost-sharing plan variation at the same metal level, if a QHP is offered at that metal level. However, if a QHP is not available at a specific metal level, such as the bronze metal level, then no plan variations will be available at that level. If a qualified individual who is an Indian, as defined by section 4 of the Indian Health Care Improvement Act is auto-enrolled in a higher level metal plan than desired, pursuant to
Comment: One commenter urged HHS to adopt a mechanism to accommodate auto-enrollment within an insurance holding company system.
Response: We disagree that a QHP issuer should be permitted to auto-enroll individuals into a product of another licensed issuer. Section 2703(c) of the
Comment: We received many comments concerning the possibility for enrollees to be re-enrolled in a plan that prevents them from continuing to receive financial assistance through the Exchange. Two specific scenarios created concern for commenters. First, commenters were concerned that enrollees might lose access to cost-sharing reductions if they are re-enrolled into a non-silver level plan. Second, commenters noted that enrollees who are re-enrolled into a product outside the Exchange would lose eligibility for both advance payments of the premium tax credit and cost-sharing reductions. We received many recommendations regarding how to address these two scenarios. Several commenters urged HHS to simply prevent issuers from auto-enrolling qualified individuals into plans outside the Exchange if the qualified individual is eligible for advance payments of the premium tax credit, or into a non-silver level plan if the qualified individual is eligible for cost-sharing reductions. Similarly, a few commenters suggested that we add consideration of a plan's cost-sharing structure as a factor in any auto-enrollment schema. Another commenter suggested that if an individual is re-enrolled in a plan that results in a negative impact on his or her financial assistance that the Exchange should permit the individual to change plans during open enrollment and for a 90-day period following open enrollment.
Response: We agree with commenters that losing access to advance payments of the premium tax credit and/or cost-sharing reductions in order to maintain coverage under a product that is no longer available through an Exchange is not the preferable outcome for renewal and re-enrollment. The hierarchy of renewal and re-enrollment options set out in
Section 155.335(j)(2) of this final rule specifically addresses re-enrollment in Exchange coverage when an enrollee's current product is not available for renewal "through the Exchange." Nonetheless, the product may continue to be available for renewal outside the Exchange. We interpret the guaranteed renewability provisions of
Final Rule Action: We are finalizing
B. Part 156--Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges; Subpart M--Qualified Health Plan Issuer Responsibilities
In 45 CFR 147.106(f)(1) of the final rule entitled, "Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond," published on
We proposed adding a new
Finally, we proposed establishing a notice requirement that would apply to all plans subject to the guaranteed renewability requirements that nonrenew coverage based on continued coverage not being available in the enrollee's service area as a result of changes that do not result in product discontinuances. We sought comment on this proposal, including the appropriate timeframe for providing the notice.
Comment: Commenters were generally supportive of the additional required content proposed for the renewal and re-enrollment notices. For example, commenters approved of the inclusion of information about changes to the advance payment of the premium tax credit and the reminders of the requirement to report changes, the reconciliation process, and the availability of cost-sharing reductions. Two commenters were concerned that the issuer notice content would not encourage enrollees to take any action. A few commenters urged issuers to ensure notices are provided in plain language and include appropriate accessibility features. Finally, one commenter recommended including language reminding enrollees to consider how changes in their enrollment might affect their access to financial assistance for health coverage and that they have the option to shop for other coverage.
Response: We appreciate the support received for the proposed additional required content for the renewal and re-enrollment notices. We note that, pursuant to
We also note that issuers are required to provide enrollees a Summary of Benefits and Coverage (SBC), a document that summarizes benefits and cost-sharing under a plan. Issuers must provide the SBC at various specific points in time, including annually upon renewal. At renewal, the SBC must reflect any modified policy or plan terms that will be effective on the first day of the new policy or benefit year. If a written application is required for renewal or reissuance, the SBC must be provided no later than the date written application materials are distributed. If renewal or reissuance is automatic, the SBC generally must be provided no later than 30 days prior to the first day of the new policy or benefit year. 45 CFR 147.200(a)(1)(ii)(E)(2) and (a)(1)(iv)(C)(2). This requirement also applies in the situation in which an issuer nonrenews or discontinues coverage under an existing health insurance product and, consistent with applicable Federal and State law, automatically enrolls an individual or plan sponsor (and participants and beneficiaries covered under such coverage) in a plan under a different product offered by such issuer in which the individuals are eligible to enroll. As such, the requirements to provide an SBC in connection with an automatic renewal or reissuance of coverage apply and the SBC generally is required to be provided no later than 30 days prior to the first day of the new policy or benefit year. An issuer is not prohibited from providing the SBC earlier than 30 days prior to the new policy or benefit year, and when possible issuers are encouraged to provide SBCs by the first day of the open enrollment period to allow individuals enough time to consider their coverage options available with respect to the upcoming policy or benefit year. If an issuer does provide the SBC earlier than 30 days prior to the new plan or policy year, and there are no changes to the information reflected in the SBC prior to the first day of the new plan or policy year, the issuer will have satisfied the requirement to provide the renewal SBC.
Comment: Some commenters were concerned that the implementation of
Response: We agree that it is important to provide enrollees with information that will help them make informed decisions about their coverage for the upcoming benefit year. As part of that process, and as discussed in the guidance issued alongside the
In the proposed rule,
Comment: We received comments regarding providing specific notice messages for re-enrollment options for American Indians and Alaskan Natives (AI/ANs). For example, cost-sharing reductions for these enrollees is implemented differently from how it is implemented for other enrollees, and the information described in
Response: We understand the concern that AI/ANs receive the appropriate messaging regarding requirements specific to their coverage. We have revised
Final Rule Action: We are finalizing the provisions proposed in
III. Collection of Information Requirements
Emergency Clearance: Public Information Collection Requirements Submitted to the
In compliance with section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 (PRA), we have also submitted to the
In the
The approval of this data collection process is essential to ensuring that renewal and discontinuance notices associated with the 2015 benefit year are provided to consumers in a timely manner prior to the open enrollment period for the 2015 benefit year. Consumers will need the information in these notices in order to make decisions regarding their coverage for the 2015 benefit year.
ICRs Regarding Renewal and Re-enrollment Notice Requirements (
As specified in
Since there are existing requirements for issuers to send renewal and discontinuance notices, we only estimate the burden for QHP issuers to revise current notices to comply with the provisions of this final rule. We estimate that there are 575 QHP issuers and assume that they would all revise their existing notices to comply with the requirements in this final rule.
For renewal notices, we estimate that, for each issuer, it will require three hours of clerical labor (at a cost of
For re-enrollment (or nonrenewal) notices, we estimate that, for each issuer, it will require two hours of clerical labor (at a cost of
The accompanying bulletin "Form and Manner of Notices When Discontinuing or Renewing a Product in the Group or Individual Market" provides that states that are enforcing the Affordable Care Act may develop their own standard notices, provided the State-developed notices are at least as protective as the Federal standard notices. However, we anticipate that fewer than 10 states would opt for this alternative. Under 5 CFR 1320.3(c)(4), this requirement is not subject to the PRA as it would affect fewer than 10 entities in a 12-month period.
We have submitted an information collection request to OMB for review and approval of the ICRs contained in this final rule. The requirements are not effective until approved by OMB and assigned a valid OMB control number.
IV. Regulatory Impact Statement
A. Summary
We are publishing this final rule to implement the protections intended by the
B. Executive Orders 12866 and 13563
Executive Order 12866 (58 FR 51735) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects; distributive impacts; and equity). Executive Order 13563 (76 FR 3821,
Section 3(f) of Executive Order 12866 defines a "significant regulatory action" as an action that is likely to result in a rule--(1) having an annual effect on the economy of
A regulatory impact analysis (RIA) must be prepared for rules with economically significant effects (for example,
1. Need for Regulatory Action
This final rule specifies additional options for annual eligibility redeterminations, and renewal and re-enrollment notice requirements for QHPs in the Exchange beginning with annual redeterminations for coverage for benefit year 2015.
2. Summary of Impacts
We do not expect that there will be additional costs related to the additional options provided in this final rule for annual eligibility redeterminations, because we believe Exchanges will implement an alternative method only if doing so is less costly than the current method.
QHP issuers will incur costs to prepare and send renewal notices to comply with the final provisions, as detailed in section III of this final rule. States that choose to develop their own notices will incur costs to do so. Providing consumers with information such as benefit changes and premium amounts will enable them to make decisions regarding their coverage for the next benefit year.
C. Regulatory Flexibility Act
The Regulatory Flexibility Act (RFA) requires agencies that issue a regulation to analyze options for regulatory relief of small businesses if a rule has a significant impact on a substantial number of small entities. The RFA generally defines a "small entity" as: (1) a proprietary firm meeting the size standards of the
D. Unfunded Mandates Reform Act
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) requires that agencies assess anticipated costs and benefits before issuing any rule that includes a federal mandate that could result in expenditure in any one year by State, local or tribal governments, in the aggregate, or by the private sector, of
UMRA does not address the total cost of a rule. Rather, it focuses on certain categories of cost, mainly those "Federal mandate" costs resulting from: (1) Imposing enforceable duties on State, local, or tribal governments, or on the private sector; or (2) increasing the stringency of conditions in, or decreasing the funding of, State, local, or tribal governments under entitlement programs.
This final rule will allow Exchanges to choose one of three methods for conducting annual eligibility redeterminations. We assume that Exchanges will choose an alternative method only if it is less costly than the current method. It will also require QHP issuers to include specific information in renewal and nonrenewal notices sent to enrollees and issuers will incur costs to comply with this requirement. States that choose to develop their own notices will incur costs to do so. Consistent with policy embodied in UMRA, this final rule has been designed to be the least burdensome alternative for State, local and tribal governments, and the private sector while achieving the objectives of the Affordable Care Act.
E. Federalism
Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a rule that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications.
States are the primary regulators of health insurance coverage, and State laws will continue to apply to health insurance coverage and the business of insurance. However, if any State law or requirement prevents the application of a Federal standard, then that particular State law or requirement will be preempted. State requirements that are more stringent than the Federal requirements will not be preempted by this final rule. Accordingly, states have significant latitude to impose requirements with respect to health insurance coverage that are more restrictive than the Federal law.
F. Congressional Review Act
This final rule is subject to the Congressional Review Act provisions of the Small Business Regulatory Enforcement Fairness Act of 1996 (5 U.S.C.
List of Subjects
45 CFR Part 146
Health care, Health insurance, Reporting and recordkeeping requirements.
45 CFR Part 147
Health care, Health insurance, Reporting and recordkeeping requirements, State regulation of health insurance.
45 CFR Part 148
Administrative practice and procedure, Health care, Health insurance, Penalties, Reporting and recordkeeping requirements.
45 CFR Part 155
Administration and calculation of advance payments of the premium tax credit, Administrative practice and procedure, Advance payments of premium tax credit, Cost-sharing reductions, Health care access, Health insurance, Reporting and recordkeeping requirements, State and local governments.
45 CFR Part 156
Administrative practice and procedure, Health care, Health insurance, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the
PART 146--REQUIREMENTS FOR THE GROUP HEALTH INSURANCE MARKET
1. The authority citation for part 146 continues to read as follows:
Authority: Secs. 2702 through 2705, 2711 through 2723, 2791, and 2792 of the PHS Act (42 U.S.C. 300gg-1 through 300gg-5, 300gg-11 through 300gg-23, 300gg-91, and 300gg-92).
2. Section 146.152 is amended by revising paragraph (b)(5) to read as follows:
* * * * *
(b) * * *
(5) Enrollees' movement outside service area. For network plans, there is no longer any enrollee under the group health plan who lives, resides, or works in the service area of the issuer (or in the area for which the issuer is authorized to do business); and in the case of the small group market, the issuer applies the same criteria it would apply in denying enrollment in the plan under
* * * * *
PART 147--HEALTH INSURANCE REFORM REQUIREMENTS FOR THE GROUP AND INDIVIDUAL HEALTH INSURANCE MARKETS
3. The authority citation for part 147 continues to read as follows:
Authority: Secs. 2701 through 2763, 2791, and 2792 of the Public Health Service Act (42 U.S.C. 300gg through 300gg-63, 300gg-91, and 300gg-92), as amended.
4. Section 147.106 is amended by revising paragraph (b)(5) to read as follows:
* * * * *
(b) * * *
(5) Enrollees' movement outside service area. For network plans, there is no longer any enrollee under the plan who lives, resides, or works in the service area of the issuer (or in the area for which the issuer is authorized to do business); and in the case of the small group market, the issuer applies the same criteria it would apply in denying enrollment in the plan under
* * * * *
PART 148--REQUIREMENTS FOR THE INDIVIDUAL HEALTH INSURANCE MARKET
5. The authority citation for part 148 continues to reads as follows:
Authority: Secs. 2701 through 2763, 2791, and 2792 of the Public Health Service Act (42 U.S.C. 300gg through 300gg-63, 300gg-91, and 300gg-92), as amended.
6. Section 148.122 is amended by revising paragraph (c)(4) to read as follows:
* * * * *
(c) * * *
(4) Movement outside the service area. For network plans, the individual no longer resides, lives, or works in the service area of the issuer, or area for which the issuer is authorized to do business, but only if coverage is terminated uniformly without regard to any health status-related factor of covered individuals; provided the issuer provides notice in accordance with the requirements of paragraph (d)(1) of this section.
* * * * *
PART 155--EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT
7. The authority citation for part 155 continues to read as follows:
Authority: Title I of the Affordable Care Act, sections 1301, 1302, 1303, 1304, 1311, 1312, 1313, 1321, 1322, 1331, 1332, 1334, 1402, 1411, 1412, 1413, Pub. L. 111-148, 124 Stat. 119 (42 U.S.C. 18021-18024, 18031-18033, 18041-18042, 18051, 18054, 18071, and 18081-18083).
8. Section 155.330 is amended by revising paragraph (b)(4) to read as follows:
* * * * *
(b) * * *
(4) The Exchange must allow an enrollee, or an application filer on behalf of the enrollee, to report changes via the channels available for the submission of an application, as described in
* * * * *
9. Section 155.335 is amended by revising paragraphs (a), (e), and (j) to read as follows:
(a) General requirement. (1) Except as specified in paragraphs (l) and (m) of this section, the Exchange must redetermine the eligibility of a qualified individual on an annual basis.
(2) The Exchange must conduct annual redeterminations required under paragraph (a)(1) of this section using one of the following:
(i) The procedures described in paragraphs (b) through (m) of this section;
(ii) Alternative procedures specified by the Secretary for the applicable benefit year; or
(iii) Alternative procedures approved by the Secretary based on a showing by the Exchange that the alternative procedures would facilitate continued enrollment in coverage for which the enrollee remains eligible, provide clear information about the process to the qualified individual or enrollee (including regarding any action by the qualified individual or enrollee necessary to obtain the most accurate redetermination of eligibility), and provide adequate program integrity protections.
* * * * *
(e) Changes reported by qualified individuals. Except as specified in paragraph (e)(1) of this section, the Exchange must require a qualified individual to report any change with respect to the eligibility standards specified in
(1) The Exchange must not require a qualified individual who did not request an eligibility determination for insurance affordability programs to report changes that affect eligibility for insurance affordability programs.
(2) The Exchange must allow a qualified individual, or an application filer, on behalf of the qualified individual, to report changes via the channels available for the submission of an application, as described in
* * * * *
(j) Re-enrollment. If an enrollee remains eligible for enrollment in a QHP through the Exchange upon annual redetermination--
(1) And the product under which the QHP in which he or she is enrolled remains available through the Exchange for renewal, consistent with
(i) The enrollee's coverage will be renewed in the same plan as the enrollee's current QHP, unless the current QHP is not available.
(ii) If the enrollee's current QHP is not available, the enrollee's coverage will be renewed in a plan at the same metal level as the enrollee's current QHP.
(iii) If the enrollee's current QHP is not available and the enrollee's product no longer includes a plan at the same metal level as the enrollee's current QHP, the enrollee's coverage will be renewed in a plan that is one metal level higher or lower than the enrollee's current QHP; or
(iv) If the enrollee's current QHP is not available and the enrollee's product no longer includes a plan that is at the same metal level as, or one metal level higher or lower than the enrollee's current QHP, the enrollee's coverage will be renewed in any other plan offered under the product in which the enrollee's current QHP is offered in which the enrollee is eligible to enroll.
(2) And the product under which the QHP in which he or she is enrolled is not available through the Exchange for renewal, consistent with
(i) The enrollee will be re-enrolled in a plan through the Exchange at the same metal level as the enrollee's current QHP in the product offered by the same issuer that is the most similar to the enrollee's current product;
(ii) If the issuer does not offer another plan through the Exchange at the same metal level as the enrollee's current QHP, the enrollee will be re-enrolled in a plan through the Exchange that is one metal level higher or lower than the enrollee's current QHP in the product offered by the same issuer through the Exchange that is the most similar to the enrollee's current product; or
(iii) If the issuer does not offer another plan through the Exchange at the same metal level as, or one metal level higher or lower than the enrollee's current QHP, the enrollee will be re-enrolled in any other plan offered through the Exchange by the same issuer in which the enrollee is eligible to enroll.
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PART 156--HEALTH INSURANCE ISSUER STANDARDS UNDER THE AFFORDABLE CARE ACT, INCLUDING STANDARDS RELATED TO EXCHANGES
10. The authority citation for part 156 continues to read as follows:
Authority: Title I of the Affordable Care Act, sections 1301-1304, 1311-1313, 1321-1322, 1324, 1334, 1342-1343, 1401-1402, Pub. L. 111-148, 124 Stat. 119 (42 U.S.C. 18021-18024, 18031-18032, 18041-18042, 18044, 18054, 18061, 18063, 18071, 18082, 26 U.S.C. 36B, and 31 U.S.C. 9701).
11. Add
A health insurance issuer that is renewing an enrollment group's coverage in an individual market QHP offered through the Exchange (including a renewal with modifications) in accordance with
(a) Premium and advance payment of the premium tax credit information sufficient to notify the enrollment group of its expected monthly premium payment under the renewed coverage, in a form and manner specified by the Exchange, provided that if the Exchange does not provide this information to enrollees and does not require issuers to provide this information to enrollees, consistent with this section, such information must be provided in a form and manner specified by HHS;
(b) An explanation of the requirement to report changes to the Exchange, as specified in
(c) For an enrollment group that includes an enrollee on whose behalf advance payments of the premium tax credit are being provided, an explanation of the reconciliation process for advance payments of the premium tax credit established in accordance with 26 CFR 1.36B-4; and
(d) For an enrollment group that includes an enrollee being provided cost-sharing reductions, but for whom no QHP under the product remains available for renewal at the silver level, an explanation that in accordance with
Dated:
Administrator,
Approved:
Secretary.
[FR Doc. 2014-21178 Filed 9-2-14;
BILLING CODE 4120-01-P
Copyright: | (c) 2014 Federal Information & News Dispatch, Inc. |
Wordcount: | 13452 |
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