Fact Sheet on Proposed Exchange Integrity Regulation

Document Excerpt
The Centers for Medicare & Medicaid Services (CMS) released a proposed rule on November 7, 2018 to strengthen program integrity for Exchanges with respect to subsidy payments in the individual market.
The proposed rule is intended to advance the Administration’s goals of:

•Strengthening CMS’ oversight over State-based Exchanges (SBEs) through monitoring,reporting, and oversight of Exchange activities to, among other things, ensure SBEs are correctly determining consumer eligibility for advance payments of the premium tax credit (APTC) and cost-sharing reduction (CSR) amounts (as applicable), and that SBEs are meeting the standards of federal law in a transparent manner;
•Safeguarding taxpayer funds by ensuring that enrollees are accurately determined eligible for APTC and CSRs (as applicable) through revisions to the periodic data matching(PDM) requirements, and an optional consumer authorization that would allow CMS to identify and resolve issues around consumers dually enrolled in Medicare and a Qualified Health Plan (QHP) through the Exchange;
•Protecting rights of conscience by enforcing requirements in the statute that require issuers to send a separate bill to consumers who selected a plan with abortion coverage for the portion of premiums attributable to abortion services for which public funding is prohibited.


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