CMS has released proposed rules for health insurance exchanges
The proposed rule released Jan. 14 also provides options for coordinating Medicaid, CHIP, and exchange communications to consumers about eligibility notices and appeals, and additional benefits and cost-sharing flexibility for state Medicaid programs under the Patient Protection and Affordable Care Act.
- Process for a coordinated exchange and Medicaid appeals of eligibility determinations. Enrollees will first be able to have a preliminary case review by appeals staff in an informal resolution. If the enrollee is satisfied, the decision stands. Enrollees dissatisfied with the outcome would have rights to a full appeal. A federally-managed appeals process would be available to enrollees in the individual market. State-based exchanges could establish their own appeals processes following the rule’s standards, with individuals retaining the right to a federal appeal after exhausting the state-based appeals process. States also may coordinate appeals of eligibility decisions across Medicaid, CHIP and the exchange.
- Notices and communications about eligibility for insurance affordability programs will be clear and accurate. The notices of insurance affordability programs will be combined, including Medicaid, CHIP, advance payments of the premium tax credit and cost-sharing reductions, as well as eligibility to enroll in a qualified health plan through the exchange.
- Medicaid cost sharing of premiums will be updated and simplified. Additionally, states will be allowed to establish higher cost sharing for non-preferred drugs and to impose higher cost sharing for non-emergency use of the emergency department.
- Eligibility categories will be streamlined. The eligibility categories that will be in effect in 2014 build on the Medicaid and CHIP eligibility final rule issued in March 2012. It shifts to use of the Modified Adjusted Gross Income, or MAGI, method for determining eligibility with most populations. It also simplifies and aligns the citizenship documentation process across Medicaid, CHIP and the exchange.