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From Health Reform WK-EDGE, November 21, 2018

CMS targets exchange systems, seeks to improve eligibility, enrollment integrity

By Kayla R. Bryant, J.D.

CMS proposed several initiatives directed toward improving the operation of the health insurance exchanges designed to ensure that subsidy payments are appropriately provided. The advance release of the proposed rule includes various improvements based on recommendations that came from various audits conducted by the HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO), and are intended to build on recent actions to improve exchange program integrity (Proposed rule, 83 FR 56015, November 9, 2018).

Eligibility and enrollment functions. Many exchange enrollees are eligible for advance premium tax credits (APTCs) under section 1412 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) or cost-sharing reduction subsidies. Although some state-based exchanges (SBEs) perform their own eligibility and enrollment functions, including determination of eligibility for subsidies, many use the federally-facilitated exchange’s infrastructure to do so.

Initiatives. CMS proposed requiring increased reporting specificity for exchanges to ensure that they are correctly finding applicants eligible for enrollment in coverage as well as subsidies. Exchanges would be required to provide annual reports showing compliance, but would also be required to demonstrate such compliance through audits. CMS also proposed, beginning in plan year 2020, requiring exchanges to conduct periodic data matching (PDM) more frequently for those enrolled in Medicare, Medicaid, and basic health plans. CMS plans to add authorizations to exchange applications that would allow an enrollee to have access to Medicare enrollment information.

Abortion coverage. CMS also focused on continued efforts to enforce requirements for issuers offering coverage for abortion services that are not eligible for federal funding under section 1303 of the ACA. The proposed rule would add new compliance reviews. In addition, CMS proposed that issuers send a separate bill to enrollees for only the portion of the premium that covers abortion services, and instruct enrollees to make an entirely separate payment for this portion of their premium.

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