Employee Benefits Compliance, Exchanges, Exchanges / Marketplaces / Subsidies, Laws, Regulations & FAQs, Marketplaces

CMS Issues Final Regs: Program Integrity Final Rule for Exchanges

On August 28, 2013, HHS/CMS issued a Final Rule on Program Integrity for Exchanges. The final rule is 300 pages.  CCIIO also issued a 3-page Fact Sheet that explains the Final Fule. 

Fact Sheet

This 3-page Fact Sheet explains the Final Rule on Program Integrity (below).  Key policies in the final rule include:

  • Oversight of QHP Issuers in Federally-facilitated Marketplace
  • Oversight and Monitoring of Privacy and Security Requirements
  • Consumer Protections for Payment and Application Assistance
  • Individual Eligibility Appeals
  • Employer Appeals in the Individual Market
    • For the other topics listed, it should be readily apparent what they pertain to.  In case this topic is not, the explanation in the Fact Sheet clarifies it: 
    • The ACA directs the Secretary of HHS to establish a separate appeals process for employers that wish to contest a Marketplace determination that the employer does not provide minimum essential coverage (MEC) that meets both minimum value and affordability standards.  Under the final rule, State-based marketplaces (SBMs) will have the flexibility to establish a state-based appeals process for employer appeals, and HHS will provide this process if the state does not opt to do so or does not operate a SBM.
  • Small Business Health Options Program (SHOP) Eligibility Appeals
  • Flexibility for States

Final Rule

 The final rule “outlines Exchange standards with respect to eligibility appeals, agents and brokers, privacy and security, issuer direct enrollment, and the handling of consumer cases. It also sets forth standards with respect to a State’s operation of the Exchange and Small Business Health Options Program (SHOP). It generally is finalizing previously proposed policies without change.”  (300 pages)


The Fact Sheet is at: 


The Final Rule is at: