The final rule on health insurance exchanges sets forth standards for agent and broker participation in government-facilitated insurance marketplaces. It also requires qualified health plans that issue exchange products "to accept a variety of payment methods."
Insurance companies and states now have a concrete set of federal rules to govern health insurance exchanges designed to guarantee program integrity, set standards, assure privacy and security, and an appeal process for consumer eligibility.
"The final rule provides for standards that would establish oversight of health insurance issuers," says a fact sheet issued by the Centers for Medicare & Medicaid Services. "This includes HHS (the Department of Health & Human Services) focusing on ensuring compliance with market-lace-related standards while preserving states' traditional role in overseeing the individual and small group insurance market."
A CMS statement said the final rule, released late Wednesday, is basically the same as the proposed rule, which was published June 19.
The exchanges begin Jan. 1, but enrollment begins on Oct. 1, when CMS says most of the provisions of the rule take effect.
The 300-page rule also affords numerous ways consumers may make payments on their monthly exchange premiums, and requires qualified health plans that issue exchange products "to accept a variety of payment methods" and let purchasers know in advance what options are offered "so they may utilize their preferred payment method."
Among the most complex parts of the document, the final rule sets forth standards for agent and broker participation in what are called federally facilitated and state facilitated marketplaces.
The rule also establishes processes for appealing eligibility denials, resolutions and due process and procedural rights of the appellant. This includes an informal resolution. If the consumer is dissatisfied with that decision, a more formal hearing could ensue.
State-based marketplaces have flexibility to implement their own appeals process in accordance with the final rule, although appellants in the individual market "retain the right to escalate their appeal to the federal appeal process managed by HHS if they remain dissatisfied" by the state-based appeals process.
The rule sets forth a separate appeals process for employers whose coverage plans do not provide "minimum essential coverage" meeting the rule's standards.