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HHS/CMS RIN: 0938-AT53 Publication ID: Fall 2019 
Title: Exchange Program Integrity (CMS-9922-F) 

This rule finalizes improvements to Exchange program integrity, including ensuring that eligible enrollees receive the correct advanced payments of the premium tax credit, and conducting effective and efficient oversight of State-based Exchanges.

Agency: Department of Health and Human Services(HHS)  Priority: Other Significant 
RIN Status: Previously published in the Unified Agenda Agenda Stage of Rulemaking: Final Rule Stage 
Major: No  Unfunded Mandates: No 
EO 13771 Designation: Regulatory 
CFR Citation: 45 CFR 155 and 156   
Legal Authority: Pub. L. 111-148, sec. 1303 and 1412   
Legal Deadline:  None

Statement of Need:

This final rule implements standards to ensure enrollees receive the correct amount of advance premium tax credit (APTC) and cost-sharing reduction (CSR) at the time of enrollment or re-enrollment via periodic data matching requirements.  In addition, the provisions in this rule strengthen the mechanisms and tools for overseeing ongoing compliance by State Exchanges with federal program requirements.  Finally, the provisions in this rule refine some of the methods for billing and collection of the separate payment for non-Hyde abortion services to better align with congressional intent regarding the separate payments provision of section 1303 of the Patient Protection and Affordable Care Act (PPACA).

Summary of the Legal Basis:

This rule addresses multiple sections in title I of the PPACA.


The policies in this rule are important for program integrity reasons. Variations on policies considered are discussed in the rule.

Anticipated Costs and Benefits:

This final rule implements standards that will have numerous effects, including ensuring that eligible enrollees receive the correct amount of APTC and CSR (as applicable); improving alignment with the separate payment requirement in section 1303 of the PPACA by requiring QHP issuers to send separate bills to policy holders for the portion of their premium attributable to non-Hyde abortion services; conducting effective and efficient monitoring and oversight of State Exchanges to ensure that enrollees are receiving the correct amount of APTC and CSRs in State Exchanges, and that State Exchanges are meeting the standards of federal law in a transparent manner; and protecting the interests of taxpayers and enrollees, and the financial integrity of Exchanges through oversight of health insurance issuers, including ensuring compliance with the requirements of section 1303 of the PPACA.  We are unable to quantify certain costs and benefits of this final rule such as benefits to enrollees for timely notification of their dual enrollment in other qualifying coverage such as Medicare, Medicaid/CHIP, and, if applicable, the BHP; potential increases in cost to states for increased oversight activities and to establish access to federal data systems to verify eligibility for or enrollment in Medicaid/CHIP or Medicare; and potential costs to enrollees such as increased out-of-pocket costs related to billing changes due to the separate payment requirements for non-Hyde abortion services.  As we move toward publication, estimates of costs and benefits will be included in the final rule.


If this regulation is not published, important program integrity improvements will not be implemented.

Action Date FR Cite
NPRM  11/09/2018  83 FR 56015   
NPRM Comment Period End  01/08/2019 
Final Action  11/00/2019 
Regulatory Flexibility Analysis Required: No  Government Levels Affected: Federal, State 
Federalism: Yes 
Included in the Regulatory Plan: Yes 
RIN Data Printed in the FR: No 
Agency Contact:
Jeff Wu
Deputy Director for Policy
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight, MS: 733H.02, 7500 Security Boulevard,
Baltimore, MD 21244
Phone:301 492-4305