CMS Proposes Rule For Exchanges And SHOPs Under The Affordable Care Act

New marketing integrity and oversight provisions warrant review and comment.

On June 14, the Centers for Medicare and Medicaid Services (CMS) in the U.S. Department of Health and Human Services (HHS) published its proposed rule "Program Integrity: Exchanges, SHOP, Premium Stabilization Programs, and Market Standards."¹ The proposed rule implements provisions under the Affordable Care Act (ACA) and addresses oversight and technical ground rules for the new Affordable Insurance Exchanges (Exchanges). HHS proposes a number of program integrity provisions, including documentation, auditing, and reporting requirements.

The proposed rule also establishes standards for Qualified Health Plan (QHP) vendors, processes to handle consumer complaints, and the process for QHPs to appeal the imposition of civil monetary penalties (CMPs) or decertification for alleged noncompliance. One of the recurring themes in the rule is HHS providing states with substantial flexibility in