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PPACA auditors are out there

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Federal agencies are starting to lay the groundwork for enforcing compliance with the Patient Protection and Affordable Care Act of 2010 (PPACA).

Staff members from the National Association of Insurance Commissioners (NAIC) gave the Florida Health Insurance Advisory Board a briefing on federal PPACA enforcement efforts Tuesday at a hearing.

Federal teams already are auditing compliance with the PPACA minimum medical loss ratio (MLR) provisions, according to a written version of the briefing. The MLR provisions require carriers  to spend at least 85 percent of large group revenue and 80 percent of individual and small group revenue on what officials classify as health care and quality improvement efforts. Carriers that miss the target must use rebate payments or other methods to make up for the gap.

Regulators also are preparing to perform PPACA market conduct audits — or evaluations of how carriers are treating customers, providers and other market players — in five states. Regulators could perform additional audits in other states, the NAIC staffers said.

In states in which the U.S. Department of Health and Human Services (HHS) is running the PPACA public exchanges, federal teams will look at the adequacy of exchange plan networks. Teams will also conduct general PPACA compliance reviews, the staffers said.

Although federal regulators can enforce many PPACA provisions, the “federal government may not prohibit the sale of a policy or use of a rate in a state,” the staffers said.

See also: How will CCIIO police the PPACA risk programs?


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