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Update: Exchanges Establishment and Eligibility Final Rule

Posted on April 10, 2012 | No Comments

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Key Developments
Implementation Briefs

By Katherine Jett Hayes and Nancy Lopez


The Department of Health and Human Services (HHS), Center for Medicare and Medicaid Services (CMS) has issued a final rule[1] addressing two previous proposed rules: “Establishment of Exchanges and Qualified Health Plans”[2] and “Exchange Functions in the Individual Market: Eligibility Determinations and Exchange Standards for Employers.”[3] The final rule addresses 1) minimum federal standards that States must meet to establish and operate exchanges, 2) the minimum standards that health insurance issuers must meet as Qualified Health Plans (QHPs), and 3) basic standards employers must meet to participate in the Small Business Health Options Program (SHOP) Exchange. CMS indicates that certain portions of the rule will be considered interim final, and the agency will accept comments on certain sections.[4] CMS also indicates in the Preamble that additional details will be made available in future guidance and rulemaking, where appropriate. For information on the proposed rules, click here. This Update describes major changes made by CMS in the final rule.

Establishment of Exchanges and Qualified Health Plans

Key Definition Changes

The final rule keeps the majority of the proposed definitions relating to Exchange operation and eligibility largely unchanged, except in the following areas:

• Applicant: The final rule revises the definition of “applicant” to include individuals who are seeking coverage for themselves or their family, to clarify that certain requirements such as verification of citizenship and lawful presence apply only to individuals who are seeking coverage, and would not, for example, apply to an individual who is seeking coverage for a family member but not for himself. The agency notes that the term would apply to individuals seeking coverage regardless of whether they were ultimately determined to be eligible for Medicaid in a non-MAGI category, whether submitted directly to the Exchange, or through a state agency then transmitted to the exchange.

• Application filer: CMS redefined the term “application filer” to align with terms used in the Medicaid final rule and the tax code, and to include an adult in the applicant’s household or family as defined in the Internal Revenue Code (IRC), or if the applicant is a minor or incapacitated, someone acting responsibly on behalf of an applicant.[5]

• Family: For purposes of administration of the premium and cost-sharing tax credits, the final rule defines and cross references section 36B of the IRC, and will be finalized in rules implemented by the Secretary of the Treasury. In addition, CMS states that an application filer must provide an attestation to the exchange regarding individuals in the household for purposes of Medicaid and Children’s Health Insurance Program (CHIP) eligibility.

• Qualified Employer: Although some commenters on the proposed rule requested an expansion of the definition of “qualified employer” to include multiple employer welfare arrangements (to be offered in the SHOP, but not the individual Exchange), and to restrict enrollment to specific industry members or organizations, the final rule requires Exchange participation standards to apply to any issuer seeking certification as a QHP. Other commenters sought to make Taft-Hartley plans and church plans available through the exchange. CMS indicated that issues related to multi-employer and church plans will be addressed in future guidance.[6]

• Lawfully Present: Although commenters proposed expanded definitions of “lawfully present,” CMS indicated that the agency will maintain the definition used in the Pre-Existing Condition Insurance Plan, which was based on section 214 of the Children’s Health Insurance Program Reauthorization Act (CHIPRA).[7]

• Medicare Secondary Payer rules relating to End Stage Renal Disease: The final rule clarifies that QHPs offered in the small group market fall under the definition of a group health plan subject to Medicare secondary payer rules under the Social Security Act, resulting in parity between SHOP and non-Exchange small group market.

Exchange Requirements and Approval[8]

The final rule left largely unchanged provisions related to the establishment of state Exchanges, permitting states to establish Exchanges as governmental agencies or non-profit organizations. CMS indicated that it would make information available to allow states to leverage work done by other states, including a web portal that will permit information sharing among states. As included in the proposed rule, the HHS Secretary must determine by January 1, 2013 whether a state Exchange will be operational by January 1, 2014. Under the final rule, states will submit an “Exchange Blueprint” (the proposed rule used the term “Exchange Plan”) to HHS. States will be notified of approval, disapproval or conditional approval. If a state fails to submit a blueprint or if the blueprint is not approved, HHS will establish an Exchange in the state.

CMS provides timeframes for the approval of significant changes to the Exchange Blueprint, permitting changes to go into effect either upon written approval by CMS or within 60 days of submission to CMS (CMS may extend consideration for an additional 30 days for good cause). In addition, CMS clarified that a state insurance agency could function as an Exchange, and that an Exchange’s board must include at least one member who is a consumer representative. Since CMS does not intend to finalize the reinsurance program as part of the Exchange rule, there is no longer a requirement to perform responsibilities related to the reinsurance program. CMS made a technical change related to non-discrimination standards and indicated that the agency will provide future guidance on the oversight and enforcement of non-discrimination standards. CMS clarified that calculations and reporting of user fees must be consistent with HHS’s medical loss ratio rule under 45 CFR 158, and that states will not be required to announce Exchange user fees on an annual basis, as required in the proposed rule, permitting states to establish a notification process.

General Exchange Functions

The final rule made a number of changes related to Exchange function in the areas of eligibility determinations and appeals. First, because CMS intends to address the content and manner of appeals of individual eligibility determinations in future rulemakings, the agency indicated that appeals have been removed from the list of minimum Exchange functions, although the final rule includes a requirement that Exchanges provide eligibility notice, including notice of the right to appeal.[9]

Consumer Assistance Tools[10]

CMS revised the proposed regulations relating to consumer assistance tools, such as websites and call centers, to require call centers to meet meaningful access standards as defined in the regulation. Citing requirements under the rule that a call center “address the needs of consumers requesting assistance,” CMS declined to add additional requirements and responsibilities related to establishing key areas of competency, referral to other sources of information, referrals to state agencies, navigators, assisters, oral translation services, providers, or specific types of services. CMS declined to require call centers to meet performance measures, and is considering recommendations regarding development of a model Website template for future guidance, including privacy and security of patient information standards.

Furthermore, the final rule directs Exchange websites to display premium and cost-sharing information and summary of benefits and coverage for each QHP, but will permit Exchanges to decide whether to make consolidated provider directories or links to QHP websites in order to meet statutory requirements. CMS clarified the final rule to permit individuals to select a QHP on the exchange website to initiate enrollment, rather than having to complete the entire enrollment process on the site. The final rule also changes requirements relating to “plain language” communications to include auxiliary aids and services, both oral and written translation, and notices that information is available in languages other than English. In addition, the final rule notes that the “meaningful access standard” is applied to Exchange notices and QHP issuer notices, indicating that specific access standard guidance would be provided in the future. In addition, the agency indicated that the final rule was modified to direct Exchanges to provide education regarding insurance affordability programs.

Navigation Program Standards[11]

In response comments on conflict of interest of Exchange Navigators, CMS requires Exchanges to develop and disseminate a set of conflict of interest standards to ensure appropriate integrity of Navigators, and defines conflict as “private or personal interest sufficient to influence or appear to influence, the objective exercise of his or her official duties.” In addition, CMS directs Exchanges to establish training standards that apply to Navigators, including both paid and unpaid staff of entities serving as Navigators. CMS indicated that the agency will issue model training standards. In response to comments, CMS clarified that Exchanges may not require Navigators to be licensed as agents or brokers. CMS also clarified that as third parties under the Exchange grant agreement, Navigators are subject to the non-discrimination standards that apply to Exchanges. The final rule requires that at least one entity serving as a Navigator be a community or consumer-focused non-profit organization, and provides a list of entitles that, among others, would meet the requirement. CMS includes in the final rule a prohibition against navigators receiving compensation from health issuers for enrolling individuals in QHPs, but clarifies that this would not preclude Navigators from receiving grants that are funded through insurance user fees, and does not preclude Navigators from receiving grants or funding from issuers for activities unrelated to enrollment. CMS clarified that subsidiaries of health insurance issuers and associations that include members or lobby on behalf of the insurance industry are prohibited from serving as Navigators.

Agents and Brokers[12]

The final rule includes a new section, as an interim final rule subject to a comment period, codifying section 1312(e) of the ACA to give states the option to permit agents and brokers to enroll individuals and employers in QHPs. Under this option, Exchanges may display information about agents and brokers on its Website or in other publicly available information. Agents and brokers may assist individuals in applying for advance payments of premium tax credit and cost-sharing reductions. CMS also seeks comments on how Exchanges could work with Web-based entities and other entities with experience in health plan enrollment. The final rule clarifies that although nothing in the final rule prohibits a QHP issuer from selling QHP coverage directly or through an agent or broker, since enrollment is not through an Exchange, enrollees are not eligible for benefits that are tied to enrollment through the Exchange, such as premium tax credit and cost-sharing assistance. The final rule establishes minimum federal standards for the use of Web-based enrollment by third parties,[13] and includes provisions to ensure that agents and brokers comply with an Exchange’s privacy and security standards and with applicable state law.

Standards for Exchange Notices[14]

CMS clarifies that applications, forms and notices issued by an Exchange must comply with the readability and accessibility standards established under §155.205(c), removes the requirement that Exchanges must re-evaluate applications, forms and notices on an annual basis (instead permitting Exchanges to determine the appropriate timing), and removed the requirement that the Exchange consult with HHS. Finally, a notice must include the reason for the intended action.

Privacy and Security of Information[15]

CMS made several modifications to the privacy and security provisions, including removing a definition of “personally identifiable information” (PII), since the term is used by all federal agencies and is defined in the Office of Management and Budget Memorandum M-07-16. CMS also indicated that the agency made significant changes to the Exchange privacy and security standards to give specific guidance to states and to ensure confidentiality for individuals who interact with the Exchange. The final rule limits the purposes for which an Exchange may use PII, prohibits the creation, collection, use or disclosure of PII unless the Exchange complies with privacy and security standards, sets expectations for the development of privacy and security protocols by an Exchange, and requires an Exchange to monitor, periodically access and update security controls. The final rule also removes references to the Health Insurance Portability and Accountability Act (HIPAA) privacy standards from proposed §155.260(b), which is now designated as paragraph (a) under this section of the rule. CMS states that this was done to avoid confusion and because the agency “believes that the privacy and security standards in the final rule are analogs of the HIPAA policies in the proposed rule, with similar standards and restrictions.” The final rule requires Exchanges to ensure that its workforce complies with requirements and applies civil penalties to each instance of knowing and willful improper use or disclosure of information.

Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs

Definitions and General Standards for Eligibility Determinations[16]

CMS included in the final rule a distinction between the use of the term “MAGI”–used for determining eligibility for premium tax credits and cost-sharing reductions–and the term “MAGI-based income,” used to denote household income for the purposes of determining Medicaid and CHIP eligibility. CMS also clarified that the term “minimum value” is used to describe coverage in an eligible employer-sponsored plan, and that the term means the plan meets the standards with respect to coverage of the total allowed cost of benefits under section 36B of the IRC, and that “insurance affordability program” includes Medicaid, CHIP and premium and cost-sharing tax credits.

Options for Conducting Eligibility Determinations[17]

CMS proposed an interim final rule and seeks comments on eligibility determinations. Specifically, an Exchange my follow state Medicaid agency rules to conduct eligibility determinations and advance payment of premium tax credits, or an Exchange can make preliminary eligibility assessments, subject to certain standards, which it then turns over to the state Medicaid agency for the final determination. The Exchange has the option to determine eligibility for advance payment of premium tax credits and cost-sharing reductions, or enter into an agreement with HHS. CMS intends to provide future guidance on this issue.

Eligibility Standards[18]

CMS revised the final rule to align residency standards with Medicaid and CHIP. CMS anticipates providing future guidance on what constitutes “reasonably expected” in regards to an applicant’s lawful presence, as well as guidance on eligibility and enrollment oversight tools and performance measurements. CMS revised eligibility criteria for advance payments on premium tax credits to align with the requirements in section 36B of the Internal Revenue Code. CMS has revised the proposed rule to include a provision on eligibility for cost-sharing reductions, and seeks comments on the proposal. Specifically, CMS adds a provision which clarifies situations where an individual with an expected household income of less than 100 percent of the federal poverty level for the benefit year in which coverage is requested would be eligible for both advance payments of premium tax credits and cost-sharing reductions; the time period for measuring income for cost-sharing reductions; and when cost-sharing reductions are available in situations where multiple tax households are covered in a single policy.

Eligibility Determination Process[19]

In response to comments concerned about the collection of social security numbers (SSNs), the final rule clarifies that an Exchange must collect an SSN (to be validated by the Social Security Administration) from any applicant that has a social security number, including a “non-applicant” if the non-applicant is a tax filer, has a SSN, and has filed a tax return for the year in which the tax data would be used. CMS further clarifies in the final rule that in order for an Exchange to authorize advance payments of the premium tax credit, it must obtain certain attestations from the tax filer (further guidance will be provided). In response to comments regarding the employer notice of an employee’s subsidy eligibility determination, CMS revises the proposed rule — which only provided that the notice identify the employee — to require the notice to include the identification of the employee, that the employer may be liable for the shared responsibility payment, and procedures for appeals. Finally, based on comments, CMS is revising the final rule to include an interim final rule at 45 C.F.R. §155.310(e) requiring an Exchange to conduct an eligibility determination promptly and without undue delay, with the timeliness commencing from the time an Exchange receives the application or the transfer from the eligibility administering agency. CMS notes that it will provide future guidance on the timeliness standard.

Verification Process Related to Eligibility for Enrollment in a QHP[20]

The final rule is revised to incorporate commenters’ suggestions that CMS specify the ways in which an applicant can submit documentation to an Exchange; thus, 45 C.F.R. §155.315(f)(2)(ii) provides that an Exchange is required to present the opportunity for an applicant to present satisfactory documentary evidence via the channels available for the submission of the application. CMS further revises this section of the final rule to specify that Exchanges “must examine” electronic records where applicable, as opposed to the “may examine” as existed in the proposed rule. The final rule allows Exchanges to have flexibility in their verification procedures by allowing Exchanges to accept an attestation of residency directly from an applicant or by examining HHS approved electronic data sources. CMS intends to provide future guidance on what documents may be used to support verification. Finally, CMS revises include as an interim final rule a new provision at 45 C.F.R. §155.315(g) allowing a case-by-case exception for applicants whose documentation does not exist or is not reasonably available (e.g., homeless individuals, victims of domestic violence or natural disasters).

Verification Process Related to Eligibility for Insurance Affordability Programs[21]

Many commenters expressed concern about the proposed standard that would limit an Exchange’s ability to follow the alternative verification process to situations where an application filer attests to the tax filer’s annual income as decreasing or expecting to decrease by 20 percent or more. The concern was that this 20 percent threshold on household income was too high and would lead to a substantial group of tax filers being unable to obtain premium tax credits proportionate to their household income, whether they could substantiate a lower income or not. In response to this concern, CMS revised the final rule to specify that an Exchange must use information other than tax data to verify income in situations where an applicant attests that a tax filer’s annual income is “reasonably expected” to decrease from his or her tax data. In addition, the final rule clarifies that as part of the alternative verification process, the Exchange must rely on attestation without any further verification if an applicant attests to his or her projected annual household income as no more than 10 percent of his or her prior tax data. In order to align the final rule with the Medicaid Eligibility final rule, CMS adopts new language in 45 §153.320(c)(2)(i)(A) to describe verification of household size. Finally, the final rule clarifies that an Exchange is required to stop advanced payments of premium tax credits and cost-sharing reductions at the end of the required 90 day inconsistency period if there is no tax data available.

Eligibility Redeterminations during a Benefit Year[22]

Exchanges may not require enrollees to report changes in income or access to minimum coverage, unless an eligibility determination is requested by the enrollee. In addition, Exchanges must notify standards for reporting changes to enrollees who request notification. The final rule gives Exchanges more flexibility to conduct data matching during the benefit year. Exchanges must notify enrollees of changes identified through data matches that will result in a change in eligibility, and allow enrollees up to 30 days to provide additional information. The final rule allows Exchanges to better align the effective dates for eligibility redeterminations and effective coverage dates by providing that changes which result from redeterminations during the benefit year must be implemented for the first day of the month following the date of the redetermination notice.

Annual Eligibility Redeterminations[23]

In response to comments regarding timing of annual redeterminations, CMS aligns annual redetermination with annual open enrollment. The final rule promotes flexibility for the Exchanges by permitting Exchanges to adjust the timing and coordination of the redetermination notices starting on January 1, 2017, as long as the timing of the notice is not earlier than the notice for annual open enrollment. CMS notes, however, that redeterminations during the benefit year do not satisfy the annual redetermination for that enrollee. Finally, the final rule clarifies that an Exchange must obtain authorization from an enrollee to request his or her tax data to conduct eligibility determinations. The authorization may be used by the Exchange for a period of up to five years.

Administration of Advance Payments of the Premium Tax Credit and Cost-Sharing Reductions[24]

The final rule adopts as an interim final provision a timeliness standard of “promptly and without undue delay” in which an Exchange must, among other actions, transmit eligibility and enrollment information to HHS. Many commenters raised privacy concerns in response to proposed rules prescribing the transmittal of information between the Exchange and HHS when an enrollee changes employers or when an enrollee receiving subsidies terminates coverage from a QHP. In response, CMS replaced Social Security Number with taxpayer identification number.

Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-Existing Condition Insurance Plan[25]

The final rule requires Exchanges to provide information and explanation to the applicant in situations in which the tax filer’s household income is not eligible for premium tax credits and at least one of the tax filer’s household members is ineligible for Medicaid. The rule also clarifies standards for coordination to align with those outlined in the Medicaid final rule. Finally, to address the concern that individuals may not be aware of coverage available to them, the final rule clarifies that the Exchange will assess information provided by the applicant to determine Medicaid eligibility on factors other than MAGI.

Exchange Functions in the Individual Market: Enrollment

Enrollment of Qualified Individuals into QHPs[27]

In the final rule, CMS clarified that Exchange websites must permit consumers to select a QHP. The final rule requires Exchanges to send enrollment information to both QHP issuers and HHS promptly and without undue delay, removing the requirement that Exchanges submit enrollment information to HHS on a monthly basis. Finally, The final rule requires Exchanges to reconcile enrollment information with QHP issuers and HHS on a basis of no less than monthly.

Initial and Annual Open Enrollment Periods[28]

In the final rule, CMS extended the end of the initial enrollment period from February 28, 2014 to March 31, 2014. In response to concerns by commenters that proposed effective dates would lead to gaps in coverage, CMS offered a couple of options, one or both of which may be offered by an Exchange. The Exchange must receive a QHP selection by the 15th of the month in order for coverage to be effective on the first day of the following month, but Exchanges may make coverage effective earlier if all QHP issuers agree. The final rule clarifies that advance payments of the premium tax credit and cost sharing reductions will not begin until the first of the month. Exchanges must send notice of annual open enrollment no earlier than September 1 and no later than September 30th of each year. CMS also provided a new option for Exchanges to automatically enroll qualified individuals, as specified by HHS, if Exchanges can demonstrate good cause for those auto-enrollments.

Special Enrollment Periods[29]

CMS will provide additional guidance relating to circumstances in which an Exchange might be required to notify individuals of the availability of coverage during special enrollment periods. CMS in the final rule modified the special enrollment period effective dates so that a QHP must receive a selection by the 15th of the month in order for coverage to be effective on the first day of the following month. As with the annual and initial enrollment period final rules, Exchanges have the flexibility to make coverage effective more quickly with the agreement of all QHP issuers, but again, premium and cost-sharing reductions will not begin until the first of the month. The same limitation regarding premium tax credit and cost-sharing reductions apply to individuals enrolling mid-month as a result of birth, adoption, or placement for adoption. In addition, CMS clarifies that loss of coverage includes those circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii), which are regulations issued by the Department of Treasury for premium tax credits relating to special circumstances including loss of minimum coverage or dependent coverage.

Termination of Coverage[30]

A number of changes were made in the final rule regarding termination of coverage from a QHP offered through an Exchange. The proposed rule specified that in instances in which an enrollee wished to terminate coverage because the enrollee obtained new minimum coverage, the last day of coverage would be the day requested by the enrollee, provided the enrollee gave “reasonable notice,” and commenters requested that CMS define the term. Under the final rule, CMS clarifies that reasonable notice is 14 days from the requested date of termination, although coverage may be terminated sooner at the request of the enrollee if the plan can terminate coverage sooner. CMS also clarifies that the grace period for non-payment of premiums is not the same 90-day grace period for non-payment of premiums for individuals receiving premium tax credits, permitting states to make the grace period consistent with existing state laws.

The final rule also broadens the reasonable accommodation requirement in terminating coverage for persons with disabilities to include anyone who meets the definition of disability in the Americans with Disabilities Act, rather than limiting the reasonable accommodation to individuals with mental or cognitive disabilities, as defined in the proposed rule. CMS removed a requirement that QHPs terminate enrollee coverage when the individual obtained other minimum essential coverage, based on comments that the rule seemed to conflict with guarantee renewability provisions in section 2703 of the Public Health Service Act. CMS removed the requirement in the final rule, noting that the individual would no longer be eligible for premium or cost-sharing reduction assistance. In response to concerns that gaps in coverage may occur if individuals are automatically terminated from Exchange coverage when they become eligible for Medicaid, the Children’s Health Insurance Program (CHIP) or a Basic Health Plan (BHP), the final rule clarifies that termination will not be automatic upon a finding of eligibility, but instead, specifies that the last day of exchange coverage is the day before Medicaid, CHIP or BHP coverage begins.

SHOP Exchanges

Establishment Standards[31]

CMS finalized SHOP standards as proposed, and added a new definition of “group participation rule”, defining the term to mean a requirement relating to the minimum number of participants or beneficiaries that must be enrolled in relation to a specified percentage or number of eligible individuals or employees of an employer.”


The final rule expanded SHOP functions to require a premium calculator and to facilitate plan choice, and it indicated that CMS will provide a model computer code to assist SHOP Exchanges in meeting the requirement. CMS also clarified that individuals who become “qualified employees” should be permitted to enroll outside of the annual open enrollment period. This would apply to new hires, as well as to other employees who become qualified outside of the initial or annual open enrollment period. CMS also clarifies that a SHOP may permit employers to offer employees a single QHP.

Under the final rule, a SHOP is responsible for providing each qualified employer with a “single bill,’ which shows aggregate premium payments from employers. CMS indicated that premium aggregation decreases the burden on employers by permitting the employer to write a single check for the total premium amount due, and that premium aggregation will not increase the administrative burden on issuers, since they will no longer have to submit, track and support a large number of paper bills to individual employers. In addition, issuers will only need to reconcile discrepancies with a single entity, rather than employers. Further CMS requires bills provided by the SHOP to contain the total amount due by the employer, the portion of each employee’s premium for which the employer is responsible as well as the employee share.

Eligibility Standards[33]

In response to multiple comments, CMS indicated that it did not have statutory authority to extend the definition of an employee to a sole proprietor, which would have allowed self-employed individuals to purchase coverage through the exchange. CMS also indicated that it is considering future rulemaking to address the method of determining employer size for purposes of deciding whether the employer is a large or small employer.

[1] Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers, 77 Fed. Reg. 18310 (March 27, 2012) (to be codified at 45 C.F.R. pts. 155, 156, and 157.
[2] 76 Fed. Reg. 41866 (proposed July 15, 2011) (to be codified at 45 C.F.R. pts. 155, 156, and 157).
[3] 76 Fed. Reg. 51202 (proposed August 17, 2011) (to be codified at 45 C.F.R. pts. 155 and 157).
[4] These sections include: §155.220(a)(3) regarding brokers, §155.300(b) regarding Medicaid and Children’s Health Insurance Program (CHIP), §155.302, regarding eligibility determinations, §155.305(g) regarding cost-sharing reductions, §155.310(e), relating to timeliness standards for Exchange eligibility determinations, §155.315(g) regarding verification for applicants with special circumstances, §155.340(d) regarding timeliness standards for transmission of information (premium tax credits and cost-sharing reductions), and §155.345(a) and §155.345(g) related to agreements between agencies administering insurance affordability programs. Preamble, 77 Fed. Reg. at p. 18311.
[5] 77 Fed. Reg. 18310 at 18313, (March 2012).
[6] 77 Fed. Reg. 18310 at 18314 (March 2012).
[7] Id.
[8] Id. at 18316-18324.
[9] Id.
[10] Id. at 18326 (§155.205).
[11] Id. 18330 (§155.210).
[12] Id. at 18334 (§155.220).
[13] Id. at 18335, citing 45 C.F.R. §155.220(c)(3).
[14] Id. at 18336 (§155.230).
[15] Id. at 18338 (§155.260).
[16] Id. at 18345 (§155.330).
[17] Id. at 1834 (§155.302).
[18] Id. at 18349 (§155.305).
[19] Id. at 18354 (§155.310).
[20] Id. at 18357 (§155.315).
[21] Id. at 18362 (§155.320).
[22] Id. at 18371 (§155.330).
[23] Id. at 18374 (§155.335).
[24] Id. at 18378 (§155.340).
[25] Id. at 18379 (§155.345).
[26] Id. at 18379 (§155.345).
[27] Id. at 18385 (§155.400).
[28] Id. at 18387 (§155.410).
[29] Id. at 18390 (§155.420).
[30] Id. at 18394 (§155.430).
[31] Id. at 18395 (§155.700).
[32] Id. at 18395 (§155.705).
[33] Id. at 18398 (§155.710).

No Comments

Public comments are closed.

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Section 1411(f) of the Affordable Care Act requires the HHS Secretary to establish a federal appeals process covering appeals related to certain determinations made by Health Insurance Marketplaces: eligibility for enrollment in a QHP sold in the Marketplace; eligibility for premium tax credits and cost-sharing reductions; exemptions from individual responsibility to maintain minimum essential coverage; citizenship and lawful presence; the affordability of employer coverage; and inconsistencies involving information.
On July 1, 2013, HHS issued final implementing regulations that specify which individuals may be eligible for exemptions from the Shared Responsibility penalty payment, a special tax established under the Affordable Care Act (ACA) that applies to non-exempt individuals who have access to affordable insurance but fail to purchase it. The final rule also explains the role of Exchanges in granting “certificates of exemption” from the penalty payments, and identifies the range of health benefits that the government will consider as satisfying the Act’s “minimum essential coverage” rule. The final rule shows some, but not a lot, of changes from its original proposed form.
A new Urban Institute analysis purports that insurance Exchanges are already exhibiting competition that will result in reasonably-priced premiums. Insurer Participation and Competition in Health Insurance Exchanges: Early Indicators Show Healthy Competition, funded by the Robert Wood Johnson Foundation, found that the six states studied have incentivized participation from multiple insurers and have relied upon market forces to drive down costs. Moreover, the report explains how the federal government may benefit from the approaches utilized by these states, as lower premiums correlate to fewer subsidies from the government in the form of premium assistance.  
According to a memo released by the Congressional Research Service (CRS), unionized individuals with multiemployer insurance plans, or Taft-Hartley plans, will not be able to purchase these plans through the Affordable Care Act's (ACA) insurance Exchanges. Most Taft-Hartley plans are self-insured, meaning the financial responsibility and risk of medical expenses are assumed by the employer rather than a larger insurance company. The self-insured status of Taft-Hartley plans prevents them from being considered a qualified health plan (QHP), a requisite characteristic for being offered on Exchanges.