At a Centers for Medicare & Medicaid Services (“CMS”) teleconference titled “Compliance Reviews in the Federally-Facilitated Marketplace” (“FFM”), which was held on April 10, 2014, CMS representatives discussed the agency’s key priorities of, and expected process for conducting, compliance reviews during the 2014 benefit year. A document titled “Key Priorities for FFM Compliance Reviews for the 2014 Benefit Year,” which was posted on the CMS Center for Consumer Information & Insurance Oversight website on April 7, 2014, lists the specific regulatory standards that CMS anticipates including in its 2014 FFM compliance reviews. These key priority areas include, among others:

  • ongoing compliance with issuer participation standards,
  • not employing marketing practice or benefit designs that will have the effect of discouraging enrollment of those with significant health needs,
  • executing appropriate delegation agreements with delegated and downstream entities,
  • ensuring compliance of appointed agents/brokers,
  • making sure that the provider network is sufficient so that services are accessible without unreasonable delay, and
  • ensuring that the qualified health plan (“QHP”) makes health plan applications and notices accessible to individuals in accordance with the Americans with Disabilities Act and for individuals with limited English proficiency.

CMS representatives emphasized that the compliance reviews to be conducted in 2014 were not intended to be punitive but rather were aimed to help educate the individual QHPs being reviewed as well as the QHP community more broadly through high-level feedback to be released by CMS subsequent to the conclusion of the 2014 reviews. QHPs  will  be  identified  for  review  through  a  risk  analysis,  though  representatives  encouraged other QHPs to volunteer for a 2014 compliance review as a learning mechanism.

CMS will begin sending selection notices during the month of April, generally providing plans with 30 days’ prior notice. Epstein Becker Green can assist plans in evaluating whether to volunteer for review and in preparing for CMS’s 2014 review of QHP compliance in the FFM.