How effective is your HIX compliance program?

Learn more about our services

​In today's complex healthcare landscape, many health plans face a significant challenge–establish a rigorous health insurance exchange regulatory compliance program or risk potential financial losses and operational disruptions by 'getting compliance wrong.' Deploying an effective compliance program should be a strategic aspiration for health plans.

Hot topics

This article discusses the following hot topics:

  1. Centers for Medicare and Medicaid Services (CMS) enforcement actions of compliance standards for health plans participating in the exchange marketplace
  2. Key areas of compliance focus for qualified health plans (QHPs) on the Federally-Facilitated Marketplaces (FFM)
  3. Steps that plans should consider to build smart and comprehensive compliance programs. Download the article to discover additional insights.

Back to top

Learn more about the additional insights


​The advent of health insurance exchanges (HIX) presents a new level of regulatory complexity to health plans. Plans must adhere to an expansive set of federal and state-level health insurance exchange regulatory requirements, some of which are known, and many which will be evolving for some time. As a result, health plans should consider acting now to create a flexible and effective health insurance exchange regulatory infrastructure, one that will allow plans to rapidly deploy compliance solutions against an evolving regulatory landscape.


Back to top

Priorities and implications

​CMS’ stated priorities have several implications for health plans:   

  • Standards of participation will evolve and will likely become “more burdensome” over time; expect federal regulators to more rigorously enforce beneficiary protections, quality, and the integrity of exchange-related programs.
  • Plans will likely be held accountable for complete, accurate, and timely enrollment processing including beneficiary notifications, eligibility, and effective dates.
  • Similar to Medicare Advantage and Part D, plans will be required to maintain and reconcile beneficiary enrollment and eligibility status with the exchange, and do so while preserving the integrity of protected health information (PHI).
  • The circumstances for terminating coverage with a beneficiary and the timeliness and accuracy of related communications will be an area of focus for regulators; maintaining records and the ability to demonstrate cause will be crucial.
  • Not only will CMS hold plans accountable for compliance-compromising events committed by their contracted entities, they expect plans to have in place robust mechanisms to prevent those events from occurring in the first place. QHP compliance programs will need to extend deep into the operations of these delegated entities in order to demonstrate effectiveness to federal regulators.

Back to top

Did you find this useful?