CMS releases final rule for state-based insurance exchanges

CMS issued a final rule Dec. 20 that aims to strengthen the integrity of state-based insurance exchanges under the ACA and includes separate billing for abortion services.

The final rule requires exchanges to conduct regular eligibility verifications with outside data sources, such as Medicare and Medicaid, at least twice annually, beginning with plan year 2021.

This eligibility verification requirement will help ensure exchanges are correctly determining consumer eligibility for advance payments of the premium tax credit and cost-sharing reduction amounts, CMS said in a news release.

"Early identification of eligibility and enrollment issues is particularly important for consumers who are eligible for or enrolled in other coverage because it can minimize the time these consumers inadvertently receive tax credits that they will have to pay back later and mitigate risks that they are not paying premiums for a plan they no longer need," the agency added.

The final rule also requires exchanges to conduct and submit findings from annual programmatic audits to the federal government. CMS has not finalized changes that clarify how extensive such audits need to be.

Additionally, the final rule requires health plans on state-based exchanges to send consumers a separate bill for certain abortion services, if their insurance covers such services. One bill would be for basic insurance and the other for abortion coverage.

CMS attributed the move to a desire to align federal regulations with ACA statutory requirements that prohibit federal funding for coverage of certain abortion services. This would apply to abortion services not protected under the Hyde Amendment, which prohibits federal funding of abortions except to save the life of the mother or in cases of incest or rape.

"The rule better aligns with Congress' intent that qualified health plans collect two distinct payments, one for the coverage of abortion services, and one for coverage of all other services covered under a qualified health plan," CMS said.

The separate billing requirements take effect June 27, while the final rule takes effect within 60 days.


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