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«Department of Health and Human Services has submitted this rule to the Office of the Federal Register. The official version of the rule will be ...»

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(vii) For plan years beginning in 2015 only, a State Insurance Commissioner should submit the recommendation specified in paragraph (b)(3)(vi) of this section, and the SHOP should make a decision based on that recommendation sufficiently in advance of the end of the QHP certification application window such that issuers can make informed decisions about whether to participate in the SHOP. In a Federally-facilitated-SHOP, State Insurance Commissioners must submit to HHS the recommendation specified in paragraph (b)(3)(vi) of this section on or before June 2, 2014, and HHS will make a decision based on any recommendations submitted by that deadline before the close of the QHP certification application window.

* * * * *

44. Section 155.725 is amended by revising paragraphs (c) and (e) to read as follows:

§155.725 Enrollment periods under SHOP.

* * * * * (c) Annual employer election period. (1) Notwithstanding any other paragraph in this section, for coverage beginning in 2015, in a Federally-facilitated SHOP a qualified employer’s annual election period may begin no sooner than November 15, 2014.

(2) The SHOP must provide qualified employers with a standard election period prior to

–  –  –

period, in which the qualified employer may change its participation in the SHOP for the next plan year, including— (i) The method by which the qualified employer makes QHPs available to qualified employees pursuant to §155.705(b)(2) and (3);

(ii) The employer contribution towards the premium cost of coverage;

(iii) The level of coverage offered to qualified employees as described in §155.705(b)(2) and (3); and (iv) The QHP or QHPs offered to qualified employees in accordance with §155.705.

* * * * * (e) Annual employee open enrollment period. The SHOP must establish a standardized annual open enrollment period for qualified employees prior to the completion of the applicable qualified employer’s plan year and after that employer's annual election period.

* * * * *

45. Section 155.740 is amended by— A. Redesignating paragraphs (g) introductory text, (g)(1) introductory text, (g)(1)(i), (g)(1)(ii), (g)(2), and (g)(3) as paragraphs (g)(1)(i) introductory text, (g)(1)(i)(A), (g)(1)(i)(B), (g)(1)(ii), and (g)(2).

B. Revising paragraph (i)(1)(i).

–  –  –

Subpart O—Quality Reporting Standards for Exchanges Sec.

155.1400 Quality rating system.

155.1405 Enrollee satisfaction survey system.

Subpart O—Quality Reporting Standards for Exchanges §155.1400 Quality rating system.

The Exchange must prominently display the quality rating information assigned to each QHP on its website, in accordance with §155.205(b)(1)(v), as calculated by HHS and in a form and manner specified by HHS.

§155.1405 Enrollee satisfaction survey system.

The Exchange must prominently display results from the Enrollee Satisfaction Survey for each QHP on its website, in accordance with §155.205(b)(1)(iv), as calculated by HHS and in a form and manner specified by HHS.

PART 156—HEALTH INSURANCE ISSUER STANDARDS UNDER THE

AFFORDABLE CARE ACT, INCLUDING STANDARDS RELATED TO EXCHANGES

47. The authority citation for part 156 is revised to read as follows:

Authority: Title I of the Affordable Care Act, sections 1301–1304, 1311–1313, 13211343, 1401–1402, Pub. L. 111-148, 124 Stat. 119 42 U.S.C. 18021-18024, 18031-18032, 18041-18042, 18044, 18054, 18061, 18063, 18071, <

–  –  –

48. Section 156.122 is amended by revising paragraph (c) to read as follows:

§156.122 Prescription drug benefits.

* * * * * (c) A health plan providing essential health benefits must have procedures in place that allow an enrollee to request and gain access to clinically appropriate drugs not covered by the health plan.

(1) Such procedures must include a process for an enrollee, the enrollee’s designee, or the enrollee’s prescribing physician (or other prescriber) to request an expedited review based on exigent circumstances.

(i) Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug.

(ii) A health plan must make its coverage determination on an expedited review request based on exigent circumstances and notify the enrollee or the enrollee’s designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 24 hours after it receives the request.

(iii) A health plan that grants an exception based on exigent circumstances must provide coverage of the non-formulary drug for the duration of the exigency.

49. Section 156.130 is amended by removing and reserving paragraph (b) and

revising paragraphs (c) and (d) to read as follows:

§156.130 Cost-sharing requirements.

* * * * *

–  –  –

(c) Special rule for network plans. In the case of a plan using a network of providers, cost-sharing paid by, or on behalf of, an enrollee for benefits provided outside of such network shall not count toward the annual limitation on cost-sharing (as defined in paragraph (a) of this section).





(d) Increase annual dollar limits in multiples of 50. For a plan year beginning in a calendar year after 2014, any increase in the annual dollar limits described in paragraph (a) of this section that does not result in a multiple of 50 dollars will be rounded down, to the next lowest multiple of 50 dollars.

* * * * *

50. Section 156.200 is amended by revising paragraph (b)(5) and adding paragraph (h) to read as follows:

§156.200 QHP issuer participation standards.

* * * * *

–  –  –

(5) Implement and report on a quality improvement strategy or strategies described in section 1311(c)(1)(E) of the Affordable Care Act consistent with the standards of section 1311(g) of the Affordable Care Act, disclose and report information on health care quality and outcomes described in sections 1311(c)(1)(H), (c)(1)(I), and (c)(3) of the Affordable Care Act, and implement appropriate enrollee satisfaction surveys consistent with section 1311(c)(4) of the Affordable Care Act;

–  –  –

(h) Operational requirements. As a condition of certification of a QHP, an issuer must attest that it will comply with all QHP operational requirements described in Subparts D, E, H, K, L and M of this part.

51. Section 156.265 is amended by revising paragraph (d) to read as follows:

§156.265 Enrollment process for qualified individuals.

* * * * * (d) Premium payment. A QHP issuer must follow the premium payment process established by the Exchange in accordance with §155.240 of the subchapter.

* * * * *

52. Section 156.270 is amended by adding a new paragraph (j) to read as follows:

§156.270 Termination of coverage for qualified individuals.

* * * * * (j) Operational instructions. QHP issuers must follow the transaction rules established by the Exchange in accordance with §155.430(e) of this subchapter.

53. Section 156.604 is amended by revising paragraphs (a)(2) introductory text and (d) to read as follows:

§156.604 Requirements for recognition as minimum essential coverage for types of coverage not otherwise designated minimum essential coverage in the statute or this subpart.

–  –  –

government agency, health insurance issuer, or plan administrator must submit the following

information to HHS:

* * * * * (d) Notice. Once recognized as minimum essential coverage, the sponsor of the coverage, government agency, health insurance issuer, or plan administrator must provide notice to all enrollees of its minimum essential coverage status and must comply with the information reporting requirements of section 6055 of the Code and implementing regulations.

54. Section 156.800 is amended by adding paragraph (d) to read as follows:

§156.800 Available remedies; Scope.

* * * * * (d) Information sharing. HHS may consult and share information about QHP issuers with other Federal and State regulatory and enforcement entities to the extent that the consultation and information is necessary for purposes of State or Federal oversight and enforcement activities.

55. Section 156.805 is amended—

–  –  –

B. By revising paragraph (e)(2).

The revisions and additions read as follows:

§156.805 Bases and process for imposing civil money penalties in Federally-facilitated Exchanges.

* * * * *

–  –  –

(2) HHS will notify the issuer in writing of any penalty that has been assessed under this subpart and of the means by which the QHP issuer or another responsible entity may satisfy the CMP assessment.

* * * * *

56. Section 156.806 is added to read as follows:

§156.806 Notice of non-compliance.

If HHS learns of a potential violation described in §156.805 or if a State informs HHS of a potential violation, prior to imposing any CMPs, HHS must provide a written notice to the

issuer, to include the following:

(a) Describe the potential violation.

(b) Provide 30 days from the date of the notice for the QHP issuer to respond and to provide additional information to refute an alleged violation.

(c) State that a civil money penalty may be assessed if the allegations are not, as determined by HHS, refuted.

57. Section 156.810 is amended— A. By revising paragraph (a)(6).

C. In paragraph (a)(9) by removing “or” after the semicolon.

D. In paragraph (a)(10) by removing the period and adding a semicolon in its place.

–  –  –

(6) The QHP no longer meets the applicable standards set forth under subpart C of Part 156.

* * * * * (12) The QHP issuer substantially fails to meet the requirements related to the cases forwarded to QHP issuers under Subpart K; or (13) The QHP issuer substantially fails to meet the requirements related to the offering of a QHP under Subpart M.

* * * * * (d) Expedited decertification process. For decertification actions on grounds described in paragraphs (a)(6), (7), (8), or (9) of this section, HHS will provide written notice to the QHP issuer, enrollees, and the State department of insurance in the State in which the QHP is

being decertified. The written notice must include the following:

* * * * *

58. Section 156.1105 is amended by adding paragraphs (d) and (e) to read as follows:

§156.1105 Establishment of standards for HHS-approved enrollee satisfaction survey vendors for use by QHP issuers in Exchanges.

* * * * * (d) Monitoring. HHS will periodically monitor HHS-approved enrollee satisfaction survey vendors to ensure ongoing compliance with the standards in paragraph (b) of this section.

–  –  –

with the standards required in paragraph (b) of this section, the survey vendor may be removed from the approved list described in paragraph (c) of this section and/or the submitted survey results may be ineligible to be included for ESS results.

(e) Appeals. An enrollee satisfaction survey vendor that is not approved by HHS after submitting the application described in paragraph (a) of this section may appeal HHS’s decision by notifying HHS in writing within 15 days from receipt of the notification of not being approved and submitting additional documentation demonstrating how the vendor meets the standards in paragraph (b) of this section. HHS will review the submitted documentation and make a final approval determination within 30 days from receipt of the additional documentation.

59. Section 156.1120 is added to subpart L to read as follows:

§156.1120 Quality rating system.

(a) Data submission requirement. (1) A QHP issuer must submit data to HHS and Exchanges to support the calculation of quality ratings for each QHP that has been offered in an Exchange for at least one year.

(2) In order to ensure the integrity of the data required to calculate the QRS, a QHP issuer must submit data that has been validated in a form and manner specified by HHS.

(3) A QHP issuer must include in its data submission information only for those QHP enrollees at the level specified by HHS.

(b) Timeline. A QHP issuer must annually submit data necessary to calculate the QHP’s quality ratings to HHS and Exchanges, on a timeline and in a standardized form and manner

–  –  –

(c) Marketing requirement. A QHP issuer may reference the quality ratings for its QHPs in its marketing materials, in a manner specified by HHS.

(d) Multi-State plans. Issuers of multi-State plans, as defined in §155.1000(a) of this subchapter, must provide the data described in paragraph (a) of this section to the U.S. Office of Personnel management, in the time and manner specified by the U.S. Office of Personnel Management.

60. Section 156.1125 is added to subpart L to read as follows:

§156.1125 Enrollee satisfaction survey system.

(a) General requirement. A QHP issuer must contract with an HHS-approved enrollee satisfaction survey (ESS) vendor, as identified by §156.1105, in order to administer the Enrollee Satisfaction Survey of the QHP’s enrollees. A QHP issuer must authorize its contracted ESS vendor to report survey results to HHS and the Exchange on the issuer’s behalf.

(b) Data requirement. (1) A QHP issuer must collect data for each QHP, with more than 500 enrollees in the previous year that has been offered in an Exchange for at least one year and following a survey sampling methodology provided by HHS.

(2) In order to ensure the integrity of the data required to conduct the survey, a QHP issuer must submit data that has been validated in a form and manner specified by HHS, and submit this data to its contracted ESS vendor.

(3) A QHP issuer must include in its data submission information only for those QHP enrollees at the level specified by HHS.

(c) Marketing requirement. A QHP issuer may reference the survey results for its QHPs

–  –  –

(d) Timeline. A QHP issuer must annually submit data necessary to conduct the survey to its contracted ESS vendor on a timeline and in a standardized form and manner specified by HHS.

(e) Multi-State plans. Issuers of multi-State plans, as defined in §155.1000(a) of this subchapter, must provide the data described in paragraph (b) of this section to the U.S. Office of Personnel management, in the time and manner specified by the U.S. Office of Personnel Management.

PART 158—ISSUER USE OF PREMIUM REVENUE: REPORTING AND REBATE

REQUIREMENTS

61. The authority citation for part 158 continues to read as follows:

Authority: Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18), as amended.

62. Section 158.150 is amended by revising paragraph (b)(2)(i)(A)(6) to read as follows:

§158.150 Activities that improve health care quality.

* * * * *

–  –  –

(6) Commencing with the 2012 reporting year and extending through the first reporting year in which the Secretary requires ICD-10 as the standard medical data code set, implementing

–  –  –

Insurance Portability and Accountability Act (HIPAA), 42 U.S.C. 1320d-2, as amended, limited to 0.3 percent of an issuer's earned premium as defined in §158.130.

* * * * *

63. Section 158.211 is amended by revising paragraph (a) to read as follows:

§158.211 Requirement in States with a higher medical loss ratio.

(a) State option to set higher minimum loss ratio. For coverage offered in a State whose law provides that issuers in the State must meet a higher MLR than that set forth in §158.210, the State's higher percentage must be substituted for the percentage stated in §158.210. If a State requires the small group market and individual market to be merged and also sets a higher MLR standard for the merged market, the State’s higher percentage must be substituted for the percentage stated in §158.210 for both the small group and individual markets.

* * * * *

64. Section 158.220 is amended by revising paragraph (a) to read as follows:

§158.220 Aggregation of data in calculating an issuer's medical loss ratio.

(a) Aggregation by State and by market. In general, an issuer's MLR must be calculated separately for the large group market, small group market and individual market within each State. However, if a State requires the small group market and individual market to be merged, then the data reported separately under subpart A for the small group and individual market in that State must be merged for purposes of calculating an issuer's MLR and any rebates owing.

* * * * *

65. Section 158.221 is amended by adding paragraphs (b)(6) and (7) to read as follows:

§158.221 Formula for calculating an issuer’s medical loss ratio.

–  –  –

(6) The numerator of the MLR in the individual and small group markets in States that adopted the transitional policy outlined in the CMS letter dated November 14, 2013 must be the amount specified in this paragraph (b), except that issuers that provided transitional coverage may multiply the total incurred claims and expenditures for activities that improve health care quality incurred in 2014 in the respective State and market by a factor of 1.0001.

(7) The numerator of the MLR in the individual and small group markets for issuers participating in the State and Federal Exchanges (sometimes referred to as “Marketplaces”) must be the amount specified in this paragraph (b), except that the total incurred claims and expenditures for activities that improve health care quality incurred in 2014 in the respective State and market may be multiplied by a factor of 1.0004.

* * * * *

66. Section 158.231 is amended by revising paragraph (a) to read as follows:

§158.231 Life-years used to determine credible experience.

(a) The life-years used to determine the credibility of an issuer's experience are the life-years for the MLR reporting year plus the life-years for the two prior MLR reporting years.

If a State requires the small group market and individual market to be merged, then life-years used to determine credibility must be the life-years from the small group market and the individual market for the MLR reporting year plus the life-years from the small group market and the individual market for the two prior MLR reporting years.

–  –  –



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