Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, and Eligibility Appeals

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 Exchange standards with respect to eligibility appeals, agents and brokers, privacy and security, issuer direct enrollment, and the handling of consumer cases. It also sets forth standards with respect to a State's operation of the Exchange and Small Business Health Options Program (SHOP). It generally is finalizing previously proposed policies without change.

DATES: These regulations are effective on September 30, 2013.

FOR FURTHER INFORMATION CONTACT: Leigha Basini at (301) 492-4380, or Noah Isserman at (301) 492-4401 for general information and matters relating to parts 155 and 156.

Seth Schneer at (301) 492-4405 for matters relating to the SHOP.

Jacob Ackerman at (301) 492-4179 for matters relating to part 147.

Jaya Ghildiyal at (301) 492-5149 for matters relating to part 153.

Christine Hammer at (301) 492-4431 for matters relating to part 155 subpart F.

Paul Tibbits at (301) 492-4229 for matters relating to part 156, subpart K.

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.

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 (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 of 2010 (Pub. L. 111-152))

AV Actuarial Value

CFR Code of Federal Regulations

CHIP Children's Health Insurance Program

CMP Civil Money Penalty

CMS Centers for Medicare & Medicaid Services

DOI State Department of Insurance

DOL U.S. Department of Labor

EFT Electronic Funds Transfer

EHB Essential Health Benefits

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

GAO United States Government Accountability Office

GLBA Gramm Leach Bliley Act

HHS U.S. Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191, as amended) and its implementing regulations

IRS Internal Revenue Service

LEP Limited English Proficiency

MAGI Modified Adjusted Gross Income

MLR Medical Loss Ratio

NAIC National Association of Insurance Commissioners

NPRM Notice of Proposed Rulemaking

OMB Office of Management and Budget

PCIP Pre-existing Condition Insurance Plan

PHI Protected Health Information

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 employees will be able to be covered by private health insurance coverage through competitive marketplaces called Affordable Insurance Exchanges, or "Exchanges" (also called Health Insurance Marketplaces). This rule sets forth standards for eligibility appeals, verification of eligibility for minimum essential coverage, and treatment of incomplete applications. It also establishes additional consumer protections regarding privacy and security; clarifies the role of agents, brokers, and issuer application assisters in assisting consumers with obtaining Exchange coverage; provides for the handling consumer cases; and establishes non-discrimination standards for methods of premium payment. Finally, it sets forth provisions regarding a State's operation of the SHOP.

Although many of the provisions in this rule will become effective by October 1, 2013, we do not believe that affected parties will have difficulty complying with the provisions by their effective dates, because the standards are based on existing standards currently in effect in the private health insurance market, were previously addressed in the Exchange Blueprint process, discussed in agency-issued sub-regulatory guidance, or discussed in the preambles to the Exchange Establishment Rule, /1/ Premium Stabilization Rule, /2/ or the HHS Notice of Benefit and Payment Parameters for 2014. /3/ In addition to comments on the substance of the provisions we are now finalizing, we sought input on ways to implement the 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

FOOTNOTE 3 Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014 and Amendments to the HHS Notice of Benefit and Payment Parameters for 2014, 78 FR 15410 and 15541 (Mar. 11, 2013). END FOOTNOTE

Table of Contents

I. Background

A. Legislative Overview

B. Stakeholder Consultation and Input

II. Provisions of the Proposed Regulations and Analysis of and Responses to Public Comments

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

1. Fair Health Insurance Premiums

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

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

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

1. Subpart A--General Provisions

2. Subpart B--General Standards Related to the Establishment of an Exchange

3. Subpart C--General Functions of an Exchange

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

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

6. Subpart F--Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs

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

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

1. Subpart A--General Provisions

2. Subpart C--Qualified Health Plan Minimum Certification Standards

3. Subpart D--Federally-facilitated Exchange Qualified Health Plan Issuer Standards

4. Subpart I--Enforcement Remedies in Federally-facilitated Exchanges

5. Subpart K--Cases Forwarded to Qualified Health Plans and Qualified Health Plan Issuers in Federally-facilitated Exchanges by HHS

6. Subpart M--Qualified Health Plan Issuer Responsibilities

III. Collection of Information Requirements

IV. Regulatory Impact Analysis

V. Regulations text

I. Background

A. Legislative Overview

The Patient Protection and Affordable Care Act (Pub. L. 111-148) was enacted on March 23, 2010. The Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), which amended and revised several provisions of the Patient Protection and Affordable Care Act, was enacted on March 30, 2010. In this final rule, we refer to the two statutes collectively as the "Affordable Care Act."

Subtitles A and C of Title I of the Affordable Care Act reorganized, amended, and added to the provisions of Title XXVII of the Public Health Service Act (PHS Act) relating to health insurance issuers in the group and individual markets and to group health plans that are non-Federal governmental plans. As relevant here, section 2701 of the PHS Act (fair health insurance premiums) provides that the premium rate charged by a health insurance issuer for non-grandfathered health insurance coverage in the individual or small group market may vary with respect to a particular plan or coverage only based on family size, rating area, age (within a ratio of 3:1 for adults), and tobacco use (within a ratio of 1.5:1).

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

Final rule.

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

RIN Number: "RIN 0938-AR82"

Citation: "78 FR 54070"

Document Number: "CMS-9957-F"

Federal Register Page Number: "54070"

"Rules and Regulations"