Get a good HIX compliance plan or lose money, Deloitte warns

Health plans participating in health insurance exchanges (HIX) that fail to set up a "rigorous" regulatory compliance strategy set themselves up for potential financial losses, operational disruptions and aggressive federal enforcement action, says a new issue brief by Deloitte.

Health plans should prepare now to manage full scale of risk across their entire enterprise by eliminating compliance silos and proactively preventing non-compliance events, authors of the report advise.

It's going to take an integrated approach to assess and manage compliance risk and careful planning to create an organization-wide response to the highest priority risks, they advise.

The report lists a host of steps that HIX health plans should consider when building a strong compliance program, including:

  • Act now to create a flexible and effective HIX regulatory infrastructure--one that will allow plans to rapidly deploy compliance solutions against an evolving regulatory landscape.
  • Plan on the Centers for Medicare & Medicaid Services being an aggressive enforcer on the federally-facilitated marketplaces (FFM). Plans will need to understand CMS protocols, processes and data sources related to HIX compliance.
  • It's fair to assume that the FFM requirements will serve as the basis for audit and oversight protocols. Deloitte expects federal regulators to define and drive the standards, with the states following suit.
  • Standards of HIX participation will evolve and will likely become "more burdensome" over time, so expect federal regulators to more rigorously enforce beneficiary protections, quality and the integrity of exchange-related programs.
  • Plans will likely be held accountable for complete, accurate, and timely enrollment processing including beneficiary notifications, eligibility and effective dates.
  • Similar to Medicare Advantage and Part D, plans will have to maintain and reconcile beneficiary enrollment and eligibility status with the exchange, and must do so while preserving the integrity of protected health information. 

State Reforum, an online network for healthcare reform implementation, might be a useful tool for compliance officers at health plans. The site offers a place to ask questions about exchange regulations. 

To learn more:
- read Deloitte's entire brief (.pdf)
- check out State Reforum