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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 Cost Sharing Reductions (CSRs) in order to ensure that enrollees do not receive undue federal assistance if other minimum essential coverage becomes available over the course of the plan year.

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 information, and grants HHS authorities to specify the target or scope of a programmatic audit around particular Exchange program areas or requirements. HHS’ stated justification for this proposed rule change is to reduce audit burdens by more closely tailoring audit requirements to the Exchange type or issue.

This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor.

Deloitte shall not be responsible for any loss sustained by any person who relies on this publication.

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Anne Phelps

Deloitte Risk and Financial Advisory
US Health Care Regulatory leader
Deloitte & Touche LLP


Daniel Esquibel
Senior manager

Deloitte Risk and Financial Advisory
Deloitte & Touche LLP


Ethan Joselow

Deloitte Risk and Financial Advisory
Deloitte & Touche LLP

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