Compliance and Enforcement

Ensuring Compliance with the Public Health Service Act

Title XXVII of the Public Health Service Act (PHS Act) contemplates that states will exercise primary enforcement authority over health insurance issuers in the group and individual markets to ensure compliance with health insurance market reforms.  In the event that a state notifies the Centers for Medicare & Medicaid Services (CMS) that it does not have statutory authority to enforce or that it is not otherwise enforcing one or more of the provisions of title XXVII, or if CMS determines that the state is not substantially enforcing the requirements, CMS has the responsibility to enforce these provisions in the state.  This enforcement framework, in place since 1996, ensures that consumers in all states have protections of the PHS Act.

If a state informs CMS that it does not have authority to enforce one or more of the applicable provisions of the PHS Act, and the state has not entered into a collaborative arrangement, CMS has the responsibility to directly enforce the relevant provisions in the state with respect to health insurance issuers in the group and individual markets.  

At any time, a state that is willing and able may assume enforcement authority of the applicable PHS Act provisions. When that happens, CMS will work with the state to ensure an effective transition.

As of April 23, 2024, the following states have notified CMS that they do not have the authority to enforce or are not otherwise enforcing the Affordable Care Act market reform provisions.

■  Missouri
■  Oklahoma
■  Tennessee
■  Texas
■  Wyoming 

Collaborative Arrangement

CMS will form a collaborative arrangement with any state that is willing and able to perform regulatory functions but lacks enforcement authority.  To the extent that CMS and a state agree on a collaborative approach, the state will perform the same regulatory functions with respect to the applicable PHS Act provisions as it does to ensure compliance with state law, and will seek to achieve voluntary compliance from issuers if the state finds a potential violation.  Similarly, consumers will continue to contact the state for inquiries and complaints relating to PHS Act requirements.  Under this collaborative approach, if the state finds a potential violation and is unable to obtain voluntary compliance from an issuer, it will refer the matter to CMS for possible enforcement action.  

CMS Enforcement

CMS, on behalf of the Department of Health and Human Services (HHS), is responsible for enforcing applicable provisions of title XXVII of the Public Health Service Act (PHS Act), including those added by the Affordable Care Act (ACA), the No Surprises Act (NSA) and the Transparency provisions of the Consolidated Appropriations Act, 2021 (CAA, 2021), and the Mental Health Parity and Addiction Equity Act (MHPAEA) with respect to health insurance issuers in certain circumstances.  CMS is also responsible for enforcing the provisions of title XXVII of the PHS Act that are applicable to non-Federal governmental plans (such as plans for state and local government employees) in all states, the District of Columbia, and the territories.  Additionally, CMS is responsible for enforcement of provisions of the NSA and Transparency provisions applicable to providers, facilities, and providers of air ambulance services in a state, if CMS determines that the state is not substantially enforcing one or more of the applicable NSA requirements.


To ensure compliance with the law, CMS conducts targeted market conduct examinations and other audit activities, as necessary, and responds to consumer inquiries and complaints. 

Federal Market Conduct Examination Final Reports

2015 

2020

2021

2024

Qualifying Payment Amount Audits

The NSA requires the Secretary of Health and Human Services (Secretary) to conduct audits to ensure that group health plans and health insurance issuers offering group or individual health insurance coverage are in compliance with the requirements related to calculation of the qualifying payment amount (QPA). 

MHPAEA NQTL Comparative Analysis Review Final Determinations

The CAA, 2021 requires the Secretary to request and review at least 20 comparative analyses per year from group health plans or health insurance issuers offering group or individual health insurance coverage (Plan or Issuer) who impose non-quantitative treatment limitations (NQTLs) on mental health or substance use disorder benefits. CCIIO has authority over MHPAEA for fully insured group and individual health insurance coverage in TX and WY and for non-Federal governmental group health plans in all states. The reports below are final determinations of a Plan or Issuer’s compliance with MHPAEA requirements, as demonstrated by review of the requested comparative analyses.

2021

2022

CMS Complaint Data and Enforcement Reports on Health Insurance Market Reforms

CMS receives complaints regarding potential instances of non-compliance with applicable provisions of title XXVII of the PHS Act, such as the requirements found in the NSA and Transparency provisions, the ACA, and MHPAEA.  In general, CMS receives information regarding potential violations of federal requirements in several different ways, including stakeholder feedback; referrals from Congress, states, or territories; No Surprises Help Desk complaints; and news articles.  The data included in the reports below are a high-level summary of the complaints CMS has received and closed as of the date of the report. 

Compliance

Policy Form Review

Policy form review is one of the compliance tools used to confirm health insurance issuers' compliance with the provisions of the health insurance market reforms of the Affordable Care Act.  Issuers required to submit form filings to CMS will need to follow instructions posted on the Training Resources webpage.

Health Insurance and Consumer Protections Grants

Many of the market reforms and consumer protections in Part A of title XXVII of the PHS Act are new provisions that became effective for plan years beginning in 2014. The Health Insurance Enforcement and Consumer Protections Grants will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal requirements and that States are able to effectively oversee and enforce these provisions. The Health Insurance Enforcement and Consumer Protections Grant program will provide $25.5 million in grant funds to assist States in implementing and/or planning the following provisions of Part A of Title XXVII of the Public Health Service (PHS) Act:

  1. Section 2707 - Non-discrimination under Comprehensive Health Insurance Coverage (Essential Health Benefits Package)
  2. Section 2713 - Coverage of Preventive Health Services
  3. Section 2718 - Bringing down the Cost of Health Care Coverage (MLR)
  4. Section 2719 - Appeals Process
  5. Section 2726 - Parity in Mental Health and Substance Use Disorder Benefits

State Flexibility to Stabilize the Market Grants

The State Flexibility to Stabilize the Market Grant Program, comprised of - (State Flexibility Cycle I and II Grants,) will provide a funding source to enhance the role of States in planning and implementing several of the Federal market reforms and consumer protections. State Flexibility Cycle I and II Grants will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal requirements, and enhance the States’ ability to effectively regulate their respective health insurance markets through innovative measures that support the pre-selected market reforms and consumer protections under Part A of Title XXVII of the Public Health Service (PHS Act). The State Flexibility Cycle I Grant program will provide $8.6 million in grant funds and the State Flexibility Cycle II Grant program will provide $19.6 million in grant funds to assist States in implementing and/or planning the following provisions of Part A of Title XXVII of the PHS Act:  

  1. Section 2702 – Guaranteed Availability of Coverage
  2. Section 2703 – Guaranteed Renewability of Coverage
  3. Section 2707 – Non-discrimination under Comprehensive Health Insurance Coverage (Essential Health Benefits Package)

 

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11/26/2024 01:21 PM
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