CMS proposes additional oversight of ACA exchanges, including abortion coverage

Seema Verma speaking at press conference
“This administration is committed to making sure taxpayer dollars are spent appropriately,” said CMS administrator Seema Verma. (

The Centers for Medicare & Medicaid Services (CMS) released a proposed rule (PDF) on Wednesday afternoon designed to increase oversight of the Affordable Care Act exchanges and ramp up enforcement of plans covering abortions.

The bulk of the rule proposes ways to prevent individuals who are enrolled in Medicare, Medicaid and other public programs from being enrolled in an exchange plan at the same time, and ensure consumers receiving subsidies are eligible for such funding.

“Maintaining a high level of program integrity on the Exchange is essential, including ensuring that premium tax credits only go to those who are eligible for them,” said CMS administrator Seema Verma in a press release.

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The exchanges currently must identify changes that would affect someone’s eligibility for subsidies in what are called periodic data matching (PDM) audits. The proposed rule would permit exchanges to allow consumers to authorize a review of their Medicare eligibility and enrollment status.

RELATED: OIG: still struggles with eligibility verification

Consumers enrolled in Medicare and an exchange plan are usually unaware that they are and terminate exchange coverage once they find out, the rule says. The changes would balance the risk pool in the individual market since "Medicare and Medicaid/CHIP beneficiaries tend to be higher utilizers of medical services,” the rule states.

If implemented, the rule would require exchanges to conduct these audits twice per year starting in 2020 for those receiving most forms of public coverage.

The remaining portion of the proposal was shorter but involves a more controversial topic: abortion.

The ACA requires plans that cover abortion services to solicit separate premium payments for abortion services, estimated “as if the coverage were included for the entire population covered." Federal law prohibits federal funds, including premium tax credits and cost-sharing reduction payments, from covering abortions except certain circumstances.

RELATED: GAO recommends changes to CMS data collection to improve oversight of special enrollment

Currently, plans can collect the abortion-related payment and the rest of the premium at once, on the same bill or invoice. The proposed rule, however, would require issuers to collect that payment separately.

That could draw backlash from some blue states, like California, that require insurers to cover abortions.

If an issuer receives a single payment from someone, it must still accept it and provide coverage, the rule states. However, CMS would expect the issuer to instruct that consumer to make the payments separately going forward.

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