HealthCare.gov issuers face a tough new compliance era

Compliance review teams at the Centers for Medicare & Medicaid Services (CMS) may be quicker to punish HealthCare.gov plan issuers for problems this year, officials say.

CMS officials talked about their review process earlier this month, at a conference for the health insurers and health maintenance organizations (HMOs) that sell qualified health plan (QHP) coverage through HealthCare.gov.

PPACA drafters created the public exchange system in an effort to help consumers shop for health coverage on an apples-to-apples basis, and to help moderate-income consumers use PPACA premium tax credit subsidies to pay for the coverage.

The exchange system began selling QHP coverage Oct. 1, 2013, and the exchange QHP coverage first took effect Jan. 1, 2014.

For the first two years of the exchange system’s existence, CMS compliance reviewers tried to take a helpful, educational approach to compliance reviews, officials said. CMS avoided imposing fines or other penalties on QHP issuers with problems if they could show they were making a good faith effort to comply with exchange program rules.

That good faith compliance policy ended Dec. 31, 2015, according to a conference slide deck posted on a semiprivate CMS website.

To look at what else CMS said about QHP compliance efforts, and how that might help the agents and brokers who are still doing business with HeathCare.gov, read on.

1. CMS is already gearing up for this year’s reviews.

CMS reviewers will use compliance and performance data from the past to pick some candidates for reviews.

The reviewers will pick other QHP issuers “for expedited compliance reviews based on specific compliance issues identified throughout the year,” officials said.

“Both standard and expedited compliance reviews may be scheduled at any time during the year,” officials said. ”A compliance review may study of all the requirements applicable to issuers offering QHPs in the [HealthCare.gov exchanges], or it may be limited to an identified area of risk.”

Federal regulations require QHP issuers to keep written documentation of their activities, including compliance activities, for 10 years.

Reviewers want to see that a QHP has written compliance policies and procedures, which should contain the origination date, the approval date, the name and title of the approvers, and the implementation date. ”Policies should be reviewed at least annually,” officials said.

One area of interest is how a QHP issuer is overseeing agents and brokers. ”Issuers are responsible for ensuring the compliance of issuers’ downstream and delegated individuals and entities,” officials said.

2. Reviewers found plenty of problems last year.

CMS has already been conducting good faith period reviews for two years. In 2015, for example, CMS reviewed 32 issuers in 17 states.

One problem the reviewers found was that many compliance policies and procedures were non-existent: The QHP issuers reviewed had no documented policies or procedures in place.

Other issuers whipped up policies or procedures after CMS started conducting reviews. Still, in other cases, the issuers had policies, but the policies did not refer directly to PPACA exchange system products, or the policies did not reflect exchange system requirements.

“Issuers should create/update their policies/procedures in a timely manner, to properly reflect [HealthCare.gov] standards and operations,” officials said.

CMS reviewers have already conducted some post-certification assessment reviews for QHPs certified for sale for 2016.

Most issuers have working provider directory and formulary website links, and most have direct links to the right kinds of benefit summaries, but most have drug formularies, or covered drug lists with “at least one drug class with an abnormally low number of unrestricted covered drugs,” officials said.