Avalere Health
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Insights

Nov 01, 2013

CMS Publishes Final Program Integrity Rule

Published

Nov 01, 2013

On Oct. 24, CMS released its final program integrity standards rule, detailing: advance payments of the premium tax credit (APTCs) and cost-sharing reductions (CSRs); the premium stabilization programs; issuers offering coverage in the Federally Facilitated Marketplace; and standards for enrollee satisfaction survey vendors.

Highlights: 

  • CMS requires an Exchange or QHP to notify enrollees within 45 days (proposed as 30 days) of error discovery related to the improper reduction of APTCs, and to refund the enrollee any excess premium paid by or for the enrollee resulting from the  error. At the discretion of the enrollee, the Exchange or QHP may apply the excess premium paid by an enrollee to the enrollee’s portion of the premium for subsequent months until the excess premium is fully refunded.
  • QHPs also have 45 days from the discovery of an improper application of CSRs to refund any excess cost-sharing paid by the enrollee or a provider. If the excess cost sharing was not paid by the provider and is not requested as a refund, the QHP must apply the excess cost sharing to the enrollee’s premium until the excess is fully refunded.
  • In future rulemaking, CMS will propose to collect reinsurance contributions in two phases: the contributions for reinsurance payments and administrative expenses will be collected at the beginning of the calendar year following the benefit year, and the contributions to the US Treasury will be collected at the end of the calendar year following the benefit year. In addition, CMS is expected to exempt certain self-funded, self-administered health plans from making reinsurance contributions for 2015 and 2016.

Exchanges and health plans received some modest relief with the extension of the refund window for errors related to the application of APTCs and CSRs, though meeting this requirement will still prove challenging – particularly if errors stemming from  healthcare.gov and the federal data hub failures continue. The exemption of certain self-funded, self-administered health plans from making reinsurance contributions is likely to prove controversial, though it is unclear which plans will fall under this exemption.

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