Health Reform WK-EDGE CMS revises EDE program audit requirements
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Friday, March 20, 2020

CMS revises EDE program audit requirements

By Elena Eyber, J.D.

CMS issued guidelines outlining EDE program audit requirements that apply to remainder of plan year 2020 and plan year 2021.

CMS issued guidelines defining Enhanced Direct Enrollment (EDE) program audit requirements and discussing requirements for prospective EDE Entities’ selection of an auditor and the scope of the operational readiness review (ORR) prospective EDE Entities must undertake to demonstrate they are prepared to provide EDE services through use of the EDE pathway. CMS revised EDE program and audit requirements for the remainder of plan year 2020 and plan year 2021, including the plan year 2021 Open Enrollment Period (OEP) (Year 3 of EDE) (CCIIO Guidelines, March 13, 2020).

EDE program. CMS is continuing to implement EDE, an optional program allowing approved EDE Entities (e.g., Qualified Health Plan issuers and web-brokers approved to participate in EDE) registered with or utilizing the Federally-facilitated Exchange and State-based Exchanges on the Federal Platform, to host an application for Exchange coverage on their own websites. Participation in EDE requires integration with a suite of Exchange application programming interfaces (APIs). The APIs allow EDE Entities approved to participate in EDE to create, modify, submit, and retrieve Exchange data.

Audit submission. CMS offers an annual audit submission window when prospective primary EDE Entities may submit audits to apply for EDE participation or seek to change phases. Prospective primary EDE Entities are entities that are seeking approval to use their EDE environments for the first time and EDE Entities already approved to use the EDE pathway that are seeking to implement a new eligibility application phase.

The audit submission window for prospective primary EDE Entities interested in implementing EDE or changing phases during Year 3 of EDE is from April 1, 2020 to June 30, 2020. CMS will conduct completeness reviews on all prospective primary EDE Entity audits submitted within the applicable submission window, however the Entity’s opportunities to correct completeness deficiencies depends on when it submits its audit in the audit submission window. CMS will not review audits until the submission window begins. There is no guarantee that every prospective primary EDE Entity that submits a complete audit within the submission window will receive approval prior to the 2021 OEP or during the 2020 calendar year. CMS strongly encourages EDE Entities to submit complete audits as early as possible within the audit submission window.

Approval process. Auditing an EDE environment may take considerable effort and time (e.g., it may take up to or more than a year). Once an Entity submits a complete audit, the approval process typically involves multiple resubmissions on behalf of the Entity. Resubmissions may stem from compliance findings in the audit submission and resubmissions, and issues and findings in the EDE environment and eligibility application. The number of resubmissions also depends on how thoroughly and quickly Entities address issues and findings. Therefore, the EDE approval process typically takes several months, and may take up to a year depending on the selected end-state phase, the quality of the build of the EDE environment, the quality of the audit and documentation submitted to CMS, and the quality and timeliness of resubmissions.

Based on CMS’s experience with prior audits, prospective EDE Entities that submit complete audits later in the audit submission window (i.e., mid-to-late May through June), depending on the quality of the submission and phase, have a low probability of going live before the OEP. No prospective EDE Entity will be approved until the Entity meets all program requirements. CMS will not review audits received after June 30, 2020.

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