Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to the HHS…

Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to the HHS Notice of Benefit and Payment Parameters for 2014

SUMMARY: This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act). Specifically, this final rule outlines financial integrity and oversight standards with respect to Affordable Insurance Exchanges, qualified health plan (QHP) issuers in Federally-facilitated Exchanges (FFEs), and States with regard to the operation of risk adjustment and reinsurance programs. It also establishes additional standards for special enrollment periods, survey vendors that may conduct enrollee satisfaction surveys on behalf of QHP issuers, and issuer participation in an FFE, and makes certain amendments to definitions and standards related to the market reform rules. These standards, which include financial integrity provisions and protections against fraud and abuse, are consistent with Title I of the Affordable Care Act. This final rule also amends and adopts as final interim provisions set forth in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 interim final rule, published in the Federal Register on March 11, 2013, related to risk corridors and cost-sharing reduction reconciliation.

EFFECTIVE DATE: These regulations are effective on December 30, 2013.

FOR FURTHER INFORMATION CONTACT: Leigha Basini at (301) 492-4380 for general information.

Jacob Ackerman at (301) 492-4179 for matters relating to Parts 144 and 147, single risk pool and catastrophic plans.

Adam Shaw at (410) 786-1091 for matters relating to the oversight of risk adjustment and reinsurance.

Jaya Ghildiyal at (301) 492-5149 for matters relating to risk corridors.

Shelley Bain at (301) 492-4453 or Anne Pesto at (410) 786-3492 for matters relating to Part 155, Subpart M.

Ariel Novick at (301) 492-4309 for matters relating to the oversight of cost-sharing reductions and advance payments of the premium tax credit.

Johanna Lauer at (301) 492-4397 for matters relating to cost-sharing reduction reconciliation.

Rebecca Zimmermann at (301) 492-4396 for matters relating to quality standards, Part 156, Subpart L.

Cindy Yen at (301) 492-5142 for matters relating to Part 156 other than cost-sharing reductions, advance payments of the premium tax credit, and quality standards.

Pat Meisol at (410) 786-1917 for matters relating to confirmation of HHS payment and collections reports.

SUPPLEMENTARY INFORMATION: This Federal Register document is also available from the Federal Register online database through Federal Digital System (FDsys), a service of the U.S. Government Printing Office. This database can be accessed via the internet at http://www.gpo.gov/fdsys.

Executive Summary

Starting October 1, 2013, qualified individuals and qualified employees may purchase private health insurance coverage through competitive marketplaces called Affordable Insurance Exchanges, or "Exchanges" (also called Health Insurance Marketplaces). This final rule sets forth oversight and financial integrity standards with respect to Exchanges, Qualified Health Plan (QHP) issuers in Federally-facilitated Exchanges (FFEs), and States with regard to the operation of risk adjustment and reinsurance programs. It establishes additional standards for special enrollment periods, survey vendors that may conduct enrollee satisfaction surveys on behalf of QHP issuers in Exchanges, and issuer participation in an FFE, and makes certain amendments to definitions and standards related to the market reform rules. These standards were proposed in a proposed rule, titled "Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards" (78 FR 37032), which was published in the Federal Register on June 19, 2013. Finally, this final rule amends standards and adopts as final interim provisions set forth in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 interim final rule, published in the Federal Register on March 11, 2013 (78 FR 15541), related to risk corridors and cost-sharing reduction reconciliation.

Although many of the provisions in this rule become effective by January 1, 2014, we believe that affected parties will not have difficulty complying with the provisions by their effective dates, because most of the standards are based on existing standards currently in effect in the private market, were previously proposed through the Blueprint process, were discussed in agency-issued sub-regulatory guidance, or were discussed in the preambles to the Exchange Establishment Rule, /1/ Premium Stabilization Rule, /2/ Market Reform Rule, /3/ or the HHS Notice of Benefit and Payment Parameters for 2014 (2014 Payment Notice). /4/ In addition to soliciting general comments on the substance of the proposed provisions, we sought input on ways to implement these policies to minimize burden.

FOOTNOTE 1 Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers, 77 FR 18310 (March 27, 2012). END FOOTNOTE

FOOTNOTE 2 Patient Protection and Affordable Care Act; Standards Related to Reinsurance, Risk Corridors and Risk Adjustment, 77 FR 17220 (March 23, 2012). END FOOTNOTE

FOOTNOTE 3 Patient Protection and Affordable Care Act; Health Insurance Market Rules; Rate Review, 78 FR 13406 (February 27, 2013). END FOOTNOTE

FOOTNOTE 4 Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014, 78 FR 15410 (March 11, 2013). END FOOTNOTE

Table of Contents

I. Background

A. Legislative Overview

B. Stakeholder Consultation and Input

II. Provisions of the Final Regulation and Analysis of and Responses to Public Comments

A. Part 144--Requirements Relating to Health Insurance Coverage

1. Subpart A--General Provisions

a. Scope and Applicability ( SEC 144.102(c))

b. Definitions ( SEC 144.103)

B. Part 147--Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets

1. Guaranteed Availability and Renewability of Coverage ( SEC 147.104 and SEC 147.106)

C. Part 153--Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment Under the Affordable Care Act

1. Subpart A--General Provisions

a. Definitions ( SEC 153.20)

2. Subpart C--State Standards Related to the Reinsurance Program

a. Maintenance of Records ( SEC 153.240(c))

b. General Oversight Requirements for State-Operated Reinsurance Programs ( SEC 153.260)

c. Restrictions on Use of Reinsurance Funds for Administrative Expenses ( SEC 153.265)

3. Subpart D--State Standards Related to the Risk Adjustment Program

a. Maintenance of Records ( SEC 153.310(c)(4))

b. Interim Report and State Summary Report ( SEC 153.310(d))

c. General Oversight Requirements for State-Operated Risk Adjustment Programs ( SEC 153.365)

4. Risk Adjustment Methodology

a. Modification to the Transfer Formula in the HHS Risk Adjustment Methodology

5. Subpart E--Health Insurance Issuer and Group Health Plan Standards Related to the Reinsurance Program

a. Reinsurance Contribution Funds ( SEC 153.400)

b. Maintenance of Records ( SEC 153.405(h) and SEC 153.410(c))

6. Subpart F--Health Insurance Issuer Standards Related to the Risk Corridors Program

a. Definitions ( SEC 153.500)

b. Calculation of Allowable Costs, Attribution and Allocation of Revenue and Expense Items, and Risk Corridors Data Requirements ( SEC 153.500, SEC 153.520, and SEC 153.530)

7. Subpart G--Health Insurance Issuer Standards Related to the Risk Adjustment Program

8. Subpart H--Distributed Data Collection for HHS-Operated Programs

a. Failure To Comply With HHS-Operated Risk Adjustment and Reinsurance Data Requirements ( SEC 153.740(a))

b. Default Risk Adjustment Charge ( SEC 153.740(b))

D. Part 155--Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act

1. Subpart D--Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs

a. Administration of Advance Payments of the Premium Tax Credit and Cost-Sharing Reductions ( SEC 155.340)

2. Subpart E--Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans

a. Special Enrollment Periods ( SEC 155.420)

3. Subpart H--Exchange Functions: Small Business Health Options Program (SHOP)

a. Enrollment Periods Under SHOP ( SEC 155.725)

4. Subpart M--Oversight and Program Integrity Standards for State Exchanges

a. General Program Integrity and Oversight Requirements ( SEC 155.1200)

b. Maintenance of Records ( SEC 155.1210)

E. Part 156--Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges

1. Subpart A--General Provisions

--This is a summary of a Federal Register article originally published on the page number listed below--

Final rule.

CFR Part: "45 CFR Parts 144, 146, 147, 153, 155, and 156"

RIN Number: "RIN 0938-AR82; RIN 0938-AR74"

Citation: "78 FR 65046"

Document Number: "CMS-9957-F2; CMS-9964-F3"

Federal Register Page Number: "65046"

"Rules and Regulations"