Pension & Benefits News Exchange program integrity rule increases oversight of state-based exchanges
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Wednesday, January 8, 2020

Exchange program integrity rule increases oversight of state-based exchanges

By Pension and Benefits Editorial Staff

In an effort to ensure that taxpayer dollars are going only to eligible enrollees and services, CMS announced in an advance release that it is stepping up oversight of state-based exchanges and implementing new requirements for coverage of certain abortion services. The final rule enhances program reporting requirements to ensure that states are correctly identifying eligible enrollees, including those who are qualified for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs). The rule also modifies the requirements for invoicing and collecting payments for coverage of certain abortion services to be more in line with the original intent of the Patient Protection and Affordable Care Act (ACA).

State exchange oversight. State exchanges are currently required to submit a financial statement, eligibility and enrollment reports, and performance monitoring data annually. They are also required to contract with an independent external auditing entity to perform annual independent external financial and programmatic audits. HHS utilizes state-based marketplace annual reporting tool (SMART), along with the annual programmatic and financial audit reports as primary oversight tools for identifying and addressing state exchange non-compliance issues.

The final rule requires state exchanges to submit annual compliance reports (such as the SMART), that encompass eligibility and enrollment reporting by state exchanges, and also include reporting on compliance across other exchange program requirements. Additionally, the rule clarifies that HHS may specify or target the scope of a programmatic audit to address compliance with particular exchange program areas or requirements. State exchanges must also ensure that the independent audits implement testing procedures or other auditing procedures that assess whether a state exchange is conducting accurate eligibility determinations and enrollment transactions.

Periodic data matching. Exchanges must periodically examine available data sources to determine whether enrollees in a qualified health plan (QHP) through an exchange with APTC or CSRs have been determined eligible for or enrolled in other qualifying coverage through Medicare, Medicaid, CHIP, or the basic health plan (BHP), if applicable. Exchanges using the federal platform currently conduct Medicare periodic data matching (PDM) and Medicaid/CHIP PDM twice a year. The final rule requires all exchanges to conduct Medicare, Medicaid/CHIP, and, if applicable, BHP PDM at least twice a calendar year beginning in 2021.

Abortion coverage. The ACA requires QHPs covering abortion services to collect a separate payment from each enrollee in such a plan for the coverage of abortion services for which public funding is prohibited. In a 2016 Payment Notice, HHS stated that the QHP issuer could satisfy the separate payment requirement by sending separate monthly bills, sending a single monthly bill that itemizes the premium amount for such coverage, or sending a notice that the monthly invoice would include a separate charge for such services. The notice also allowed for the enrollee to make a single payment for coverage of such services and for coverage of all other services.

HHS now believes that this method is inconsistent with the intent of Congress. Therefore, the new rule requires QHPs to send an entirely separate monthly bill to the policy holder for the portion of the premium attributable to coverage of abortion services. The QHP must also instruct the policy holder to pay that portion of their premium in a separate transaction from any payment for the portion of their premium not attributable to coverage of those services. Finally, the QHP should counsel enrollees to pay in two separate transactions.

SOURCE: https://www.cms.gov/newsroom/press-releases/cms-announces-enhanced-program-integrity-efforts-exchange

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