Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards

SUMMARY: This proposed rule sets forth 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 proposes additional standards with respect to agents and brokers. These standards, which include financial integrity provisions and protections against fraud and abuse, are consistent with Title I of the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act.

EFFECTIVE DATE: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on July 19, 2013.

ADDRESSES: In commenting, please refer to file code CMS-9957-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the "Submit a comment" instructions.

2. By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-9957-P, P.O. Box 8010, Baltimore, MD 21244-8010.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-9957-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. Alternatively, you may deliver (by hand or courier) your written comments ONLY to the following addresses prior to the close of the comment period:

a. For delivery in Washington, DC--Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members. Comments erroneously mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Leigha Basini at (301) 492-4307, or Noah Isserman at (301) 492-4401 for general information. Ariel Novick at (301) 492-4309, for matters related to cost-sharing reductions and advance payments of the premium tax credit.

Adam Shaw at (410) 786-1091, for matters related to the risk adjustment, reinsurance and risk corridors programs.

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

Cindy Yen at (301) 492-5142, for matters related to Part 155, Subparts C and E, and Part 156.

Scott Dafflitto at (301) 492-4198, for matters relating to SHOP.

Jacob Ackerman at (301) 492-4179, for matters related to Parts 144 and Part 147 and the single risk pool.

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

SUPPLEMENTARY INFORMATION:

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

Electronic Access

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.

Acronyms and Short Forms

Because of the many organizations and terms to which we refer by acronym in this proposed rule, we are listing these acronyms and their corresponding terms in alphabetical order below:

Affordable Care Act The Affordable Care Act of 2010 (which is the collective term for the Patient Protection and Affordable Care Act (Pub. L. 111-148) and the Health Care and Education Reconciliation Act (Pub. L. 111-152))

ALJ Administrative Law Judge

APTC Advance payments of the premium tax credit

ARF Allowable rating factor

AV Actuarial Value

CAHPS(R) Consumer Assessment of Healthcare Providers and Systems

CFR Code of Federal Regulations

CMP Civil money penalty

CMS Centers for Medicare & Medicaid Services

DOI State Department of Insurance

DOL U.S. Department of Labor

FEHB Federal Employees Health Benefits

FFE Federally-facilitated Exchange

FFE API Federally-facilitated Exchange application programming interface

FF-SHOP Federally-facilitated Small Business Health Options Program

GAAP Generally-accepted accounting principles

GAAS Generally accepted auditing standards

GAGAS Generally accepted governmental auditing standards

GAO United States Government Accountability Office

HHS U.S. Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191)

IRS Internal Revenue Service

MLR Medical Loss Ratio

NAIC National Association of Insurance Commissioners

NCQA National Committee for Quality Assurance

OIG Office of the Inspector General of the U.S. Department of Health and Human Services

OMB Office of Management and Budget

PHS Act Public Health Service Act

PII Personally Identifiable Information

PRA Paperwork Reduction Act

QHP Qualified Health Plan

SHOP Small Business Health Options Program

The Code Internal Revenue Code of 1986

TIN Taxpayer Identification Number

Executive Summary

Starting on January 1, 2014, qualified individuals and qualified employers will be able to be covered by private health insurance through competitive marketplaces called Affordable Insurance Exchanges, or "Exchanges" (also called Health Insurance Marketplaces). This proposed rule sets forth oversight and financial integrity standards with respect to Exchanges, QHP issuers in Federally-facilitated Exchanges (FFEs), and States with regard to the operation of risk adjustment and reinsurance programs. It also proposes additional standards for special enrollment periods, survey vendors that may conduct enrollee satisfaction surveys on behalf of QHP issuers in Exchanges, issuer participation in an FFE, and States' operation of a SHOP. Finally, it proposes additional standards for agents and brokers, geographic rating areas, and guaranteed availability and renewability. Nothing in these proposed regulations would limit the authority of the Office of the Inspector General of the U.S. Department of Health and Human Services (OIG) as prescribed by the Inspector General Act of 1978 or any other law.

Although many of the proposed provisions in this proposed rule would become effective by 2014, we do not believe that affected parties will have difficulty complying with the provisions by their effective dates, because 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, or were discussed in the preambles to the Exchange Establishment Rule, /1/ Premium Stabilization Rule, /2/ and the HHS Notice of Benefit and Payment Parameters for 2014. /3/ In addition to general comments on the substance of the proposed provisions, we seek input on ways to implement these proposed 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

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

Proposed rule.

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

RIN Number: "RIN 0938-AR82"

Citation: "78 FR 37032"

Document Number: "CMS-9957-P"

Federal Register Page Number: "37032"

"Proposed Rules"