ACA Now

Implementation Status

2012

The March 27, 2012, Exchange establishment final rule lays out timeliness standards for transmitting information for the administration of advance payments of the premium tax credit and cost-sharing reductions.

On May 23, 2012, Treasury issued a final rule on the health insurance premium tax credit.

2013

HHS’s March 11, 2013, final rule – the Notice of Benefit and Payment Parameters for 2014 – includes provisions relative to this section’s implementation, namely the determination of advance-able premium tax credits and point-of-service cost-sharing subsidies paid to plans on enrollees’ behalf.

On April 12, 2013, CMS issued an information collection regarding processes whereby QHPs would report to HHS on the reconciliation reporting option – pertaining to advance payments of cost-sharing reductions they have received from the agency – that they have selected for a benefit year.

On May 14, CCIIO released FAQs on Health Insurance Marketplaces addressing issues involving: (1) CMS oversight of state-operated premium stabilization programs, advance payments of the premium tax credit and cost-sharing reductions; (2) issuer oversight in Federally Facilitated Marketplaces; (3) State-Based Marketplace reporting requirements; (4) privacy and security standards for State-Based Marketplaces and consumer assistance personnel; (5) cost-sharing reductions and health savings accounts; (6) eligibility and enrollment – specifically, CMS’s intent to “propose rulemaking and supplemental guidance on the use of [Health Plan Identifiers] in enrollment and payment transactions between issuers and the Federally Facilitated Marketplace”; and (7) issuer withdrawal from the small group or large group market.

On June 28, the IRS released a notice of proposed rulemaking regarding the information that Exchanges are required to report to the IRS regarding health insurance premium tax credits, among other specified details. The proposed rule provides more specific rules on reporting of information – which, the IRS notes, helps enable such functions as the reconciliation of the premium tax credit with advance credit payments. Comments are due on or around August 28, 2013.

Via a June 28 Federal Register Notice pursuant to Paperwork Reduction Act procedures, CMS published a new information collection request (and request for a new OMB control number) under which Qualified Health Plan issuers would report on the option they have selected for reconciliation of HHS’s advanced payments of cost-sharing reductions. CMS noted it had not received any comments on the information collection requirements in a 60-day comment period that began April 12.

On July 5, CMS issued a final rule with wide-ranging eligibility provisions, including several regarding Exchanges’ eligibility and enrollment. Specifically, before January 1, 2015, State-based Exchanges may “accept the applicant’s attestation regarding enrollment in an eligible employer-sponsored plan and eligibility for qualifying coverage in an eligible employer sponsored plan for the benefit year for which coverage is requested without further verification.” For income verification, for the first year of operations, rule note that CMS is “providing Exchanges with temporarily expanded discretion to accept an attestation of projected annual household income without further verification” applicable to individuals who are not part of a statistically-significant sampling strategy that is delineated in the rule. Other provisions address, among others, authorized representatives, enrollment-related transactions, special enrollment periods and terminations. Also see a July 8 Paperwork Reduction Act package related to information collection under the Exchange-related provisions of this rule.

On July 2, IRS published in the Federal Register a notice of proposed rulemakingregarding the information that Exchanges are required to report to the agency regarding health insurance premium tax credits, including specific rules on reporting of information by Exchanges to help enable such functions as the reconciliation of the premium tax credit with advance credit payments. Comments are due on Sept. 3, 2013.

On August 5, CCIIO posted a Q&A on Health Insurance Marketplaces’ income verification procedures regarding the “multi-step process” for income verification, reiterating the specific parameters for the latitude being provided to State-based Marketplaces in 2014 on verifying applicants’ income in certain cases and clarifying that – for Federally Facilitated Marketplaces – sample sizes for verification in specified instances will be set at 100%. CCIIO Director Gary Cohen, at an August 1 hearing of the House Ways & Means Committee, had testified (also see hearing page) that the guidance would provide for across-the-board income verification, and on the same day, CMS Administrator Marilyn Tavenner testified at the House Energy & Commerce Committee that such 100% verification would apply to Federally Facilitated Marketplaces (details on the latter hearing here).

On August 5, HHS’s Office of Inspector General released a report finding that any “additional delays in completing the security assessment and testing” for the Federal Data Services Hub – a facilitator of Exchanges’ access to federal agencies’ data relevant to eligibility verification – could result in CMS having “limited information on [Hub-related] security risks and controls before the Exchanges open.”

On August 30, CCIIO published a wide-ranging final rule (also see a factsheet) on Marketplace program integrity and other provisions, noting that it “generally is finalizing previously proposed policies without change.” The rule addressed oversight of Qualified Health Plan (QHP) issuers in Federally Facilitated Marketplaces; individual and SHOP eligibility appeals, including details on a “federally-managed appeals process [that] will be available for appellants in the individual market”; HHS privacy and security-related Marketplace compliance monitoring; an option for a state to operate a State-based SHOP, while having a Federally Facilitated Individual Marketplace; standards regarding issuers’ acceptance of various payment methods from Marketplace consumers; provisions addressing agents and brokers; QHP issuer direct enrollment; and a clarification regarding certain outside-the-Marketplaces plans’ participation in the risk corridors program.

On August 30, HHS released a Paperwork Reduction Act (PRA) Package including details on information collections associated with the August 30 Marketplace Program Integrity final rule, the provisions of which addressed an aspect of the risk corridors program, agents and brokers in Federally Facilitated Marketplaces and various other issues. The PRA package also contains provisions on additional information collections related to Navigators, certified application counselors and habilitative services, among other topics.

On September 12, the IRS posted a Q&A providing an overview of the premium tax credit, including an explanation of income and family size changes affecting adjustment and reconciliation of the advance and actual subsidy amount. On September 12, the House passed the No Subsidies without Verification Act (HR 2775), which, among other provisions, would preclude premium subsidies until a certified verification process is in place; the White House issued an SAP opposing the bill. On September 27, CCIIO released guidance noting that in light of a recent IRS ruling, “the eligibility rules with respect to premium tax credits under Code section 36B treat same-sex spouses in the same manner as opposite-sex spouses.” CMS said that while Federally Facilitated Marketplaces will be ready to implement the ruling by October 1, State-Based Marketplaces “may be unable to adjust systems to reflect the Ruling and this guidance by October 1, 2013” and “must implement this guidance as soon as reasonably practicable,” adding that states “must implement interim workarounds where reasonably practicable.”

On September 18, CMS sent a proposed rule to OMB for review relating to “Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards,” including wide-ranging provisions, including those relating to the risk adjustment, risk corridors and reinsurance, as well as advance payments of the premium tax credit and cost-sharing reductions, among other issues.

On October 7, CCIIO issued an FAQ specifying that QHP issuers must send FFMs confirmed enrollments by December 16 to receive subsidy payments in January 2014. State-Based Marketplaces have the same deadline.

On October 21, the IRS released a 1-pager on the premium tax credit and how consumers, depending on how they choose to avail themselves to it, if eligible, can “get it now or get it later.”

On October 24, CMS released a final rule (see a CCIIO fact sheet) codifying certain program integrity-related components of the ACA pertaining to Exchanges, premium stabilization programs and market standards that were delineated in a June 2013 proposed rule. The final rule also amends and adopts as final provisions delineated in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 interim final rule with comment issued in March 2013 related to risk corridors and reconciliation of cost-sharing.

On Nov. 4, CCIIO posted slides explaining the process – and specific information – required for enabling monthly cost-sharing reduction and advance premium tax credit payments to health insurers. On Nov. 6, House Ways and Means Committee Chairman Dave Camp (R-MI) asked the IRS to supply data on subsidy eligibility determinations conducted for Marketplace applicants, including the average age of those applying. On Nov. 12, CMS posted a chart generally characterizing, based on income, whether consumers may be eligible for premium tax credits, cost-sharing reductions or Medicaid. Also on Nov. 12, CMS posted the authorization form through which QHP issuers verify that CMS may make deposits or adjustments in transmitting premium subsidy and cost-sharing reduction payments. Also see a Financial Information Template, Bank Verification Letter Instructions and Payee and Banking Information Submission Instructions. In an e-mail, the agency notes that issuers should e-mail the template and authorization agreement to vendor_management@cms.hhs.gov, while faxing decryption codes and bank verification letters to 301-492-4746 by Dec. 1, 2013.

On Nov. 4, the House Oversight and Government Reform Committee released notes taken during CCIIO “war room” meetings between Oct. 3-Oct. 21 (see here; also see a Committee release) – supplied in response to Committee requests – explaining that while Federal Marketplace “paper applications allow people to feel like they are moving forward in the process and provide another option, at the end of the day, we are all stuck in the same queue.” The notes regarding paper applications, from Oct. 11, explain that “the same portal is being used to determine eligibility no matter how the application is submitted (paper, online)…and there is coordination to improve that experience.”

In a Nov. 5 letter to the IRS, Sens. Hatch (R-UT) and Coburn (R-OK) asked the IRS to detail safeguards for preventing and recovering advance premium tax credits.

On Nov. 25, HHS issued a proposed rule establishing the CY 2015 benefit and payment parameters for the cost-sharing reductions (including the annual limitation on cost-sharing for stand-alone dental plans), advance premium tax credit, reinsurance, and risk adjustment programs as required by the ACA.  In addition, the proposed rule establishes the user fees for the Federally-facilitated Exchanges (FFEs), the annual open enrollment period for 2015, the actuarial value (AV) calculator, and other key provisions as required by the law.  Note that the rule allows for adjustments to the risk corridors and other premium stabilization programs in 2014 to account for the “transitional policy” (see the Nov. 14 CCIIO letter to Insurance Commissioners) that addressed plan cancellations, which could equate to broader risk corridors and thus higher stabilization payments to plans. Comments are due by Dec. 26, 2013.

On Dec. 3, 2013 a newly posted Treasury Inspector General for Tax Administration report, dated September 2013, indicated that the IRS’s premium tax credit systems should follow “systems development controls” for security and fraud mitigation, among other functions.

On Dec. 9, 2013, HHS’s Assistant Secretary for Planning and Evaluation (ASPE) issued a report examining, in part, African Americans’ potential qualification for advance premium tax credits.

On Dec. 17, 2013 noting that certain counties in Washington state and Wisconsin will not have QHPs available through SHOPs, the IRS issued a notice providing targeted transition relief (see examples and a list of counties on p. 5) under which coverage provided in 2014 will qualify for the ACA’s small business tax credit as long as it would have qualified under pre-2014 rules, when purchasing through the SHOP was not a condition of receiving the credit. The IRS adds that “this treatment applies with respect to the health plan year beginning in 2014, including any portion of that plan year that continues into 2015.”

On Dec. 31, in a report required by the October 2013 budget deal and reflecting compliance with ACA requirements, Secretary Sebelius certified that Marketplaces verify applicants’ eligibility for advance payments of premium tax credits and cost-sharing reductions. The report examines State-Based and Federal Marketplaces’ approaches to verifying specific data elements that range from residency to household income and family size, among others.

2014

On Jan. 15, U.S. District Judge Paul Friedman, in denying the plaintiffs’ motion for summary judgment and granting summary judgment to defendant HHS, ruled that the statute “must be read as allowing the IRS to deliver tax credits to individuals purchasing health insurance on federally-facilitated Exchanges”;

In mid-January, CMS began paying, via an interim payment process (see Jan. 13 slides providing an overview), advance payments of the premium tax credit and cost-sharing reductions to Qualified Health Plans, net of Federally Facilitated user fees, if applicable.

On Jan. 21, HHS released its Annual Update to Poverty Guidelines that will apply to premium subsidy eligibility in 2015.

On Jan. 23, 2014, the IRS posted a fact sheet on premium tax credits, including details on claiming the credit on 2014 tax returns that will be filed in 2015.

On Jan. 30, HHS published a proposed extension to an already approved information collection (see #1, “Payment Collection Operations Contingency Plan”)  enabling it to obtain issuers’ manually entered, Excel-based payment and enrollment data used to make premium subsidy and cost-sharing reduction payments on an interim basis. The agency indicated HHS will use the information collected to make payments and collect charges in January 2014 and for a number of months thereafter, as may be required based on HHS’ operational progress.” Comments are due on or around March 30.

On Feb. 24, HHS sent the final CY 2015 Notice of Benefit and Payment Parameters rule to OMB for review, the final step before issuance of the regulation. It addresses ’15 parameters for ACA premium stabilization programs, as well as advance premium tax credits and cost-sharing reductions.

On Feb. 25, as part of a consumer-oriented “Tax Tip” series, the IRS released background information on the individual mandate penalty (here) and how changes in circumstances affect premium subsidies (here), among other topics.

On March 24, CMS posted slides presenting the April 2014 timeline for making advance premium subsidy and cost-sharing reduction payments (see slide 7).

On June 19, 2014, HHS released a report finding, among other things, that QHP enrollees through 36 Federally Facilitated Marketplaces (FFMs) who received premium tax credits paid an average of $82 monthly (76% less than the average full premium of $346) across metal levels and $69 monthly for silver plans. On June 16, CMS posted IRS town hall slides discussing  premium subsidies, including eligibility; the potential impact of changes in circumstances; relevant IRS forms providing documentation; and the mechanics of advance subsidy reconciliation. Also see a 1-pager on additional premium subsidy-related resources. On June 10, the House Ways and Means Subcommittees on Oversight and Health held a joint hearing to examine the implementation of the ACA’s income and insurance verification systems. On June 6, CMS released a notice modifying an existing computer matching program with the Social Security Administration (SSA) that facilitates Marketplace eligibility data needs. It said it was revising the estimated number of fiscal year 2014 transactions (for matched CMS-SSA records) from 5.6 million to 11.8 million in the highest month and from 5.6 million to nearly 18.2 million for the year. On May 29,the IRS issued a publication orienting consumers to the changes in circumstances they should report to Marketplaces if they are having advance payments of premium subsidies made to their QHP.

On Aug. 12, CMS announced it had sent letters to 310,000 consumers in Federally Facilitated Marketplace (FFM) plans (state-by-state breakdown) who have pending citizenship or immigration “data matching errors,” saying they must submit outstanding documentation by September 5 or their coverage will end on September 30. The agency said the FFM has resolved 450,000 citizenship and immigration status-related application inconsistencies, with an additional 210,000 “in progress,” of 970,000 cases that were outstanding in May 2014; as many as 60,000 documents are being received daily. Providing operational guidance accompanying CMS’s August 12 release, on August 13 CCIIO described end-of-month QHP and subsidy termination for Federal Marketplace enrollees with outstanding data-match issues involving citizenship or immigration status. On Aug. 13, Rep. Marsha Blackburn (R-TN) wrote a letter to HHS asking about the internal agency process for verifying applications with citizenship and immigration inconsistencies and about the agency’s plans for acting on OIG findings about income-related inconsistencies, as well.

In August 13 slides, CMS outlines September Marketplace payment processing and enrollment reporting and restatement. Also see the certification form (Word document) to accompany the September Enrollment and Payment template (Excel document) submission. The agency also posted a timeline of making interim payments of advance premium subsidies and cost-sharing reductions through October 2014.

On Aug. 19, HHS posted details on submitting documentation to the Federally Facilitated Marketplace to address pending eligibility data-match inconsistencies, such as those involving citizenship, immigration status, veteran status and income.

On August 19, CMS circulated additional resources for assisters and consumers on resolving application inconsistencies, including: slides with tips on resolving data-match or application inconsistency issues and a listing of documents consumers can provide to resolve inconsistencies; and a fact sheet for assisters on data match-driven QHP terminations.

On August 20, CMS sent a final rule, “Annual Eligibility Determinations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards,” to OMB for regulatory clearance, which marks a final step before issuance of the regulation. In June 2014, a proposed rule and accompanying guidance had laid out a pathway for auto-enrollment of Federal Marketplace QHP consumers to remain in the same plan for the 2015 benefit year.

On August 26, CMS published a notice requesting comments on an extension of a currently approved information collection (see #4 on pgs. 2-3) regarding the agency’s “Payment Collection Operations Contingency Plan” through which issuers manually report enrollment and payment data to HHS. The agency notes that it will use the data to “make payments or collect charges from issuers under the following programs: Advance payments of the premium tax credit, advanced cost-sharing reductions, and Marketplace user fees,” adding that the agency “will use the information collected to make payments and collect charges in January 2014 and for a number of months thereafter, as may be required based on HHS’s operational progress.” Comments are due by September 25, 2014.

On Oct. 23, the IRS released a consumer “tax tip” that highlighted reporting changes in circumstances to assure accurate receipt of advance premium tax credit and minimize reconciliation.

On Jan. 20, 2015, CCIIO presented operationally focused slides on cost-sharing reductions and advance premium tax credit calculations in the context of passive Marketplace reenrollment.

On Jan. 28, HHS announced that it is collaborating with non-profit organizations and certain large tax preparers to help consumers understand how the ACA impacts their taxes.

On Mar. 20, CMS and Treasury said those who filed their taxes based on an incorrect 1095-A form will not have to re-file an amended tax return. CMS also said the “vast majority” now have access to a corrected 1095-A.

On July 15, GAO released a report describing fictitious individuals’ ability to enroll via Healthcare.gov, with premium subsidies.

On July 16, On July 16, the Senate Finance Committee held a hearing on Federally Facilitated Marketplace fraud controls.