The final rule, titled “Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium Stabilization Programs and Market Standards; Amendments to the HHS Notice of Benefit and Payment Parameters for 2014,” focuses on program integrity standards for advance payments of the premium tax credit, cost-sharing reductions for lower-income exchange plan enrollees, the premium stabilization programs, state exchanges, oversight of issuers, and standards for HHS-approved enrollee satisfaction survey vendors.
The rule also amends standards and finalizes interim provisions set forth in the interim final rule, "Amendments to the HHS Notice of Benefit and Payment Parameters for 2014," published last March, related to risk corridor calculations and cost-sharing reduction reconciliation.
HHS said the goal of the provisions is to safeguard federal funds and to protect consumers by ensuring that insurers, exchanges and other entities comply with federal standards meant to ensure consumers have access to quality, affordable health insurance.
One of HHS's key goals is ensuring that eligible enrollees receive the correct tax credit and cost-sharing reductions. HHS establishes timeframes for refunds to eligible enrollees and providers when an insurer or exchange incorrectly applies advance payments 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.
The final rule establishes standards for the oversight of the state exchanges through monitoring, reporting and oversight of financial activities and Marketplace activities. These mechanisms would ensure that consumers are properly given their choices of coverage available, they receive the full amount of advance payments of the premium tax credit and cost-sharing reductions for which they qualify, and that state exchanges meet ACA standards in a transparent manner.
The final rule provides for oversight of health insurance issuers. This includes ensuring compliance with exchange requirements, such as the maintenance of records requirement and participation in investigations and compliance reviews.
The ACA provides for the development of an enrollee satisfaction survey that will be available to the public and will allow for the easy comparison of enrollee satisfaction levels among comparable plans in the exchanges. The final rule sets forth a process for approving and overseeing survey vendors to administer the survey on behalf of QHP issuers in the Marketplace.
The rule also aligns risk corridor calculations and finalizes standards permitting insurers to use an alternate methodology for calculating the value of cost-sharing reductions provided, for the purpose of reconciliation of advance payments of cost-sharing reductions.
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