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Regulation and Compliance > Federal Regulation

HealthCare.gov plans with data woes face pay threat

By Allison Bell

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The Centers for Medicare & Medicaid Services (CMS) may hold cash back from HealthCare.gov exchange plan issuers that fail to send it complete, accurate policy reports for 2016 coverage through a new automated intake system.

CMS wants the carriers that sell coverage through HealthCare.gov to begin using the automated system to file their policy reports in January.

See also: 3 ways the PPACA data filing mess makes insurers want to SCREAM

The automated reports are supposed to provide the information CMS uses to compute Patient Protection and Affordable Care Act (PPACA) advance premium tax credit (APTC) subsidy payments, PPACA cost-sharing reduction (CSR) subsidy payments and HealthCare.gov issuer user fee payments. Up till now, carriers have been sending CMS the required information using spreadsheets.

CMS officials are hoping the shift to automated reporting system will increase the accuracy of the information they’re getting, reduce administrative costs, and help them spot exchange system trends and problems more quickly.

See also: PPACA risk programs: Will those kidneys work?

CMS will start by having HealthCare.gov issuers file policy reports both through the manual process and the new automated process, according to officials at the Center for Consumer Information & Insurance Oversight (CCIIO), the CMS division in charge of the public exchange program. 

If an issuer is having problems with filing acceptable automated policy reports from April through June, CMS will withhold 25 percent of the total amount it expects to pay the issuer until the issuer starts using the automated filing system, CCIIO officials say in a bulletin.

If an issuer is still having automated filing problems, CMS will withhold 50 percent of the total amount it expects to pay the issuer until the issuer starts using the automated filing system.

“If non-compliance continues over an extended period of time, CMS will determine the need for further proration or compliance actions,” CCIIO officials say. “We note that issuers with advance payments withheld may not require consumers to pay additional premiums or cost-sharing to recoup withheld payments.”

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