CMS proposes new data matching rules for ACA Exchange Program Integrity has been saved
CMS proposes new data matching rules for ACA Exchange Program Integrity
New requirements for state-based exchanges, others
As proposed, state-based exchanges would be required to conduct more frequent data matching processes to help avoid situations in which individuals might be enrolled in an exchange plan and other health coverage. The proposed rule would codify policies for state-based exchanges to demonstrate compliance with standards related to financial performance, as well as eligibility and enrollment reports.
November 9, 2018 | Health care
On November 9, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to revise oversight standards for state-based exchanges (SBEs) established under the Affordable Care Act (ACA) and create new requirements on data matching frequency, among other provisions.
Comments on the proposed rule are due to CMS by January 8, 2019.
Highlights of select key provisions of the proposed rule are provided below.
SBE data matching requirements
Current regulations require that SBEs conduct periodic data matching (PDM) to assess consumer eligibility for Advance Premium Tax Credits (APTCs) and
In keeping with current regulations for the Federally Facilitated Exchanges (FFEs), the proposed rule would require SBEs to conduct Medicare, Medicaid/CHIP, and Basic Health Program, eligibility screenings at least twice a year beginning in 2020 for consumers receiving APTCs or CSRs. A state’s PDM system would not be required to determine whether an individual is enrolled in employer-sponsored coverage.
Citing instances where a consumer is unknowingly enrolled in Medicare, the proposed rule would establish a process that would let Qualified Health Plan (QHP) applicants or enrollees authorize the sharing of data with Exchanges to identify cases in which an individual could be dually enrolled in a QHP and other health coverage, such as Medicare. This authorization would cover all QHP consumers, including those who do not receive APTCs or CSRs.
SBEs and SBEs on the Federal Platform (SBE-FP)
The US Department of Health and Human Services (HHS) approves an SBE or SBE-FPs based on the state’s attestation of compliance with statute and regulations. On an annual basis, SBE/FPs must submit a financial statement, eligibility and enrollment reports, and performance monitoring data. State Exchanges must also undergo an independent external audit, and report any findings or recommended corrective action plans to HHS.
The proposed rule codifies the use of the State-based Marketplace Annual Reporting Tool (SMART) as the means for submitting Exchange compliance
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Impacts on health plans, health systems, life sciences companies and state health agencies in the health care marketplace