Most of the proposal focuses on program integrity for state marketplaces and insurance companies offering coverage in the federally facilitated exchanges. The rule intends to safeguard federal money and consumers.
The Centers for Medicare and Medicaid Services has unveiled its proposed rules governing the operation of health insurance exchanges [PDF] which aim to facilitate and regulate the sale of private coverage to millions of people beginning Jan. 1, 2014, under the Patient Protection and Affordable Care Act.
CMS released the 253-page proposal on Friday afternoon with little fanfare or notice. The agency said most of the proposal focuses on program integrity for state marketplaces and insurance companies offering coverage in the federally facilitated exchanges, advance payments of the premium tax credit and cost-sharing reductions, and premium stabilization programs.
The proposed rule intends to safeguard federal money and consumers by ensuring that insurance companies and marketplaces actually provide consumers with access to affordable health insurance with reasonable benefits. Consumers in every state will be able to buy insurance from qualified health plans directly through these marketplaces and may be eligible for tax credits to lower the cost of their health insurance.
A public comment period for the proposed rule extends for 90 days.
"In just a few months, consumers across the country will have access to a new Marketplace in their state where they can easily shop for health insurance that meets their needs and the needs of their families," CMS Administrator Marilyn Tavenner said in prepared remarks. "The release of these guidelines signals that we're ready to build on our ongoing efforts and ensure that the new systems are fiscally sound."
The rule also proposes establishing standards for Department of Health and Human Services-approved enrollee satisfaction survey vendors, standards for the handling of consumer complaints, and other provisions to ensure smooth operation of the marketplaces, protect consumers, and give flexibility to states, CMS said in a media release.
A marketplace consumer call center will soon offer program information and then help consumers with open enrollment and plan selection on Oct. 1. CMS will also begin consumer assistance training this summer to help consumers find the right plan.
CMS issued an outline of the proposed rule that highlights key policies:
State-operated premium stabilization programs
HHS proposes standards for the oversight of states that operate either risk adjustment or reinsurance programs. The rule would require that states keep an accurate accounting for the programs, submit to HHS and make public reports on operations, and take other steps to ensure the soundness and transparency of the programs.
Advance payments of the premium tax credit and cost-sharing reductions
HHS proposes timeframes for refunds to eligible enrollees and providers, as applicable, when an issuer incorrectly applies the advance payment of the premium tax credit or cost-sharing reductions, or incorrectly assigns an individual to a plan variation (or a standard plan without cost-sharing reductions).
HHS also proposes general standards necessary for the oversight of these payments, including the maintenance of records, annual reporting of summary level statistics, and audits.
State marketplaces
State marketplace oversight mechanisms would assure that consumers are properly given their choices of coverage available, that consumers correctly receive advance payments of the premium tax credit or cost-sharing reductions if they qualify, and that marketplaces meet PPACA standards.
Flexibility for states
HHS is proposing additional state flexibility by permitting state-based Small Business Health Options Programs (SHOP) while HHS would operate an individual market federally-facilitated marketplace in that state.
Consumer protections for enrollment assistance
This rule clarifies the ways that agents and brokers will help consumers and small businesses in federally facilitated marketplaces.
Establishment of standards for HHS-approved enrollee satisfaction survey vendors
PPACA calls for an enrollee satisfaction survey that will allow the public to compare enrollee satisfaction among comparable plans in the marketplace. This rule sets forth a process for approving and overseeing survey vendors to administer the survey on behalf of qualified health plan issuers in the marketplace.
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.