Enforcement for Misconduct or Noncompliance
CMS noted they intend to perform compliance reviews and will take enforcement action against misconduct or noncompliance. While this enforcement would apply to applicable agents, brokers, and web-brokers, they are proposing to extend their authority to lead brokers and agencies.[26]
CMS noted a significant number of enrollments (640,000) did not identify a specific individual agent or broker, but instead used the identification number of an agency only. They also noted that they had found evidence of agencies directing employees to engage in misconduct, for example not speaking to individuals before enrolling them in plans and entering inaccurate income information to result in a zero premium plan, causing problems for the consumer in the tax reconciliation process where they may owe significant dollars.
They are also soliciting comments if they should seek enforcement against individuals (lead agents) allowing other agents to use their identification number while engaging in misconduct.
CMS proposed to include system suspensions as part of their enforcement authority if they discover unacceptable risk to accuracy of eligibility determinations, noncompliance with standards of conduct or privacy and security standards until adequately remedied according to HHS.[27]
Grace Period Payment Threshold
If an enrollee has not made their premium payments in full, the ACA provides for a grace period which is a certain period (1-3 months) where premiums can be made to keep enrollment. If payments are not made by the end of the grace period, enrollment would be terminated. However, some enrollees receive APTC credits that pay a significant portion of their premiums. In this case, it may not be beneficial for the enrollee or the issuer to cancel enrollment prematurely. A threshold is already in effect whereby if 95% of premiums are paid, issuers would not need to institute a grace period.
An alternative fixed dollar amount is proposed to allow issuers to use a fixed dollar payment threshold so issuers would not be required to trigger grace period or terminated enrollees for non-payment. [28] Suggested at $5 of less, inflation adjusted but CMS is soliciting comments on the level. The fixed dollar would have to be applied uniformly. A premium percentage threshold is already in effect (95% of premium paid or higher), so this would allow issuers to another choice.
A note was provided that some payment should always be required to effectuate enrollment, aka a binder payment, to show that a consumer desires coverage.
[26] C. Part 155—Exchange Establishment Standards and Other Related Standards -2. Ability of States To Permit Agents and Brokers and Web-Brokers To Assist Qualified Individuals, Qualified Employers, or Qualified Employees Enrolling in QHPs (§155.220) – a. Engaging in Compliance Reviews and Taking Enforcement Actions Against Lead Agents for Insurance Agencies
[27] C. Part 155—Exchange Establishment Standards and Other Related Standards -2. Ability of States To Permit Agents and Brokers and Web-Brokers To Assist Qualified Individuals, Qualified Employers, or Qualified Employees Enrolling in QHPs (§155.220) – b. System Suspension Authority
[28] C. Part 155—Exchange Establishment Standards and Other Related Standards – 5. Establishment of Optional Fixed- Dollar Premium Payment Threshold and Total Premium Threshold (§155.400(g))