Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program

42 CFR Part 600

Administrative practice and procedure, Health care, Health insurance, Intergovernmental relations, Penalties, Reporting and recordkeeping requirements.

45 CFR Part 150

Administrative practice and procedure, Health care, Health insurance, Penalties, Reporting and recordkeeping requirements.

45 CFR Part 155

Administrative practice and procedure, Advertising, Brokers, Conflict of interests, Consumer protection, Eligibility criteria, Exemptions, Grants administration, Grant programs-health, Health care, Health insurance, Health maintenance organizations (HMO), Health records, Hospitals, Indians, Individuals with disabilities, Intergovernmental relations, Loan programs-health, Medicaid, Organization and functions (Government agencies), Public assistance programs, Reporting and recordkeeping requirements, Technical assistance, Women and youth.

45 CFR Part 156

Administrative practice and procedure, Advertising, Advisory committees, Brokers, Conflict of interests, Consumer protection, Grant programs-health, Grants administration, Health care, Health insurance, Health maintenance organization (HMO), Health records, Hospitals, Indians, Individuals with disabilities, Loan programs-health, Medicaid, Organization and functions (Government agencies), Public assistance programs, Reporting and recordkeeping requirements, State and local governments, Sunshine Act, Technical assistance, Women, and Youth.

For the reasons set forth in the preamble, the Department of Health and Human Services and the Centers for Medicare & Medicaid Services amends 42 CFR part 600 and 45 CFR subtitle A, subchapter B, as set forth below:

Title 42

PART 600--ADMINISTRATION, ELIGIBILITY, ESSENTIAL HEALTH BENEFITS, PERFORMANCE STANDARDS, SERVICE DELIVERY REQUIREMENTS, PREMIUM AND COST SHARING, ALLOTMENTS, AND RECONCILIATION

0 1. The authority citation for part 600 continues to read as follows:

Authority: Section 1331 of the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148, 124 Stat. 119), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-- 152, 124 Stat. 1029).

0 2. Section 600.5 is amended by adding the definition of “Eligible noncitizen” in alphabetical order as follows:

Sec. 600.5 Definitions and use of terms.

* * * * *

Eligible noncitizen has the meaning given in 45 CFR 155.20. * * * * *

Title 45

PART 150--CMS ENFORCEMENT IN GROUP AND INDIVIDUAL INSURANCE MARKETS

0 3. The authority citation for part 150 continues to read as follows:

Authority: 42 U.S.C. 300gg through 300gg-63, 300gg-91, and 300gg-92, as amended.

0 4. Section 150.317 is amended by revising the introductory text to read as follows:

Sec. 150.317 Factors CMS uses to determine the amount of penalty.

In determining the amount of any civil money penalty, CMS will identify the lawful purpose or purposes of the penalty, and take into account the following factors as appropriate to the circumstances of the case: * * * * *

PART 155--EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT

0 5. The authority citation for part 155 continues to read as follows:

Authority: 42 U.S.C. 18021-18024, 18031-18033, 18041-18042, 18051, 18054, 18071, and 18081-18083.

0 6. Section 155.20 is amended by-- 0 a. Adding the definition “Eligible noncitizen” in alphabetical order; and 0 b. Removing the definition “Standardized option”.

The addition reads as follows:

Sec. 155.20 Definitions.

* * * * *

Eligible noncitizen means an “eligible alien,” as defined in 26 U.S.C. 36B(e)(2)(B). * * * * *

Sec. 155.105 [Amended]

0 7. Section 155.105 is amended by removing paragraph (b)(4).

0 8. Section 155.106 is amended by revising paragraph (a)(2) to read as follows:

Sec. 155.106 Election to operate an Exchange after 2014.

(a) * * *

(2) Submit an Exchange Blueprint application for HHS approval at least 15 months prior to the date on which the Exchange proposes to begin open enrollment as a State Exchange.

(i) Public notice. Upon submission of an Exchange Blueprint application to operate a State Exchange, the State shall issue a public notice of its Exchange Blueprint application submission through its website and include a copy of the Exchange Blueprint application, a description of the Plan Year for which the State seeks to transition to a State Exchange, language indicating that the State is seeking approval from HHS to transition to a State Exchange, and information about when and where the State will conduct public engagements regarding the State's Exchange Blueprint application, as described in paragraph (a)(2)(ii) of this section.

(ii) Public engagements. After a State issues its public notice as described in paragraph (a)(2)(i) of this section and until HHS approves, or conditionally approves, the State's Exchange Blueprint application, a State must conduct at least one public engagement (such as a townhall meeting or public hearing) either in-person or virtually, regarding the State's Exchange Blueprint application progress, in a timeline and manner considered effective by the State and with HHS' concurrence. A State shall provide public notice of the public engagement. Such public engagement shall also provide interested parties the opportunity to learn about the State's progress in transitioning to a State Exchange and offer input on that transition. Following the initial public engagement described in this paragraph and until HHS approves or conditionally approves the State Exchange Blueprint application, a State shall conduct periodic public engagements, either in-person or virtually, in a timeframe and manner considered effective by the State. * * * * *

0 9. Section 155.170 is amended by revising paragraph (a) to read as follows:

Sec. 155.170 Additional required benefits.

(a) Additional required benefits. (1) A State may require a QHP to offer benefits in addition to the essential health benefits. For plan years beginning before January 1, 2028, a benefit required by State action taking place on or before December 31, 2011, a benefit required by State action for purposes of compliance with Federal requirements, or a benefit covered in the State's EHB-benchmark plan is considered an EHB. A benefit required by State action taking place on or after January 1, 2012, other than for purposes of compliance with Federal requirements, that is not a benefit covered in the State's EHB- benchmark plan is considered in addition to the essential health benefits.

(2) For plan years beginning on or after January 1, 2028, a State may require a QHP to cover benefits in addition to the essential health benefits, which are any State-required benefits that are:

(i) Required by a State action taking place after December 31, 2011;

(ii) Applicable to the small group and/or individual markets;

(iii) Specific to required care, treatment, or services; and

(iv) Not required by State action for purposes of compliance with Federal requirements.

(3) A State must make payments in accordance with paragraph (b) of this section to defray the cost of any State-required benefits in addition to the EHB. * * * * *

0 10. Section 155.205 is amended by revising paragraph (b)(1) introductory text to read as follows:

Sec. 155.205 Consumer assistance tools and programs of an Exchange.

* * * * *

(b) * * *

(1) Provides standardized comparative information on each available QHP and at a minimum includes: * * * * *

0 11. Section 155.220 is amended by-- 0 a. Removing paragraph (c)(3)(i)(H); 0 b. Redesignating paragraphs (c)(3)(i)(I) through (M) as paragraphs (c)(3)(i)(H) through (L), respectively; 0 c. Revising paragraph (j)(2)(i); 0 d. Revising paragraph (j)(2)(ii)(A) introductory text; 0 e. Redesignating paragraph (j)(2)(ii)(A)(2) as paragraph (j)(2)(ii)(A)(3); 0 f. Adding new paragraph (j)(2)(ii)(A)(2);

0 g. Revising paragraph (j)(2)(iii)(A); 0 h. Redesignating paragraph (j)(2)(iii)(C) as paragraph (j)(2)(iii)(D); 0 i. Adding new paragraph (j)(2)(iii)(C); 0 j. Redesignating paragraph (j)(3) as paragraph (j)(4); and 0 k. Adding new paragraph (j)(3).

The revisions and additions read as follows:

Sec. 155.220 Ability of States to permit agents and brokers and web- brokers to assist qualified individuals, qualified employers, or qualified employees enrolling in QHPs.

* * * * *

(j) * * *

(2) * * *

(i) Provide consumers with correct information, without omission of material fact, regarding the Federally-facilitated Exchanges, QHPs offered through the Federally-facilitated Exchanges, and insurance affordability programs, and refrain from conduct that is misleading (including by having a direct enrollment website that HHS determines could mislead a consumer into believing they are visiting HealthCare.gov), coercive, or discriminates based on race, color, national origin, disability, age, or sex;

(ii) * * *

(A) Documenting that eligibility application information has been reviewed by and confirmed to be accurate by the consumer or the consumer's authorized representative must require the consumer or their authorized representative to take an action that produces a record that can be maintained by the individual or entity described in paragraph (j)(1) of this section and produced to confirm the consumer or their authorized representative has reviewed and confirmed the accuracy of the eligibility application information. For enrollments for plan years ending prior to January 1, 2028, non-exhaustive examples of acceptable documentation include obtaining the signature of the consumer or their authorized representative (electronically or otherwise), verbal confirmation by the consumer or their authorized representative that is captured in an audio recording, a written response (electronic or otherwise) from the consumer or their authorized representative to a communication sent by the agent, broker, or web-broker, or other similar means or methods specified by HHS in guidance. * * * * *

(2) For enrollments for plan years beginning on or after January 1, 2028, including enrollments under Sec. 155.335(j), all documentation required under paragraph (j)(2)(ii)(A) of this section must be collected by having the consumer or the consumer's authorized representative take an action to execute an HHS-approved and -created consumer consent form. The action the consumer or the consumer's authorized representative took to confirm the eligibility application information has been reviewed and confirmed to be accurate must be clear to HHS. This may include hand-written or electronic written signature or initials on the HHS-approved and -created consumer consent form, an email from the consumer or the consumer's authorized representative, or a recorded verbal conversation. A signature that is simply typed on the documentation or a filled-in check box does not clearly indicate the eligibility application information was reviewed and confirmed accurate by the consumer or the consumer's authorized representative. * * * * *

(iii) * * *

(A) Obtaining and documenting the receipt of consent must require the consumer, or the consumer's authorized representative designated in compliance with Sec. 155.227, to take an action that produces a record that can be maintained and produced by an individual or entity described in paragraph (j)(1) of this section to confirm the consumer's or their authorized representative's consent has been provided. For enrollments for plan years ending prior to January 1, 2028, non- exhaustive examples of acceptable documentation of consent include obtaining the signature of the consumer or their authorized representative (electronically or otherwise), verbal confirmation by the consumer or their authorized representative that is captured in an audio recording, a response from the consumer or their authorized representative to an electronic or other communication sent by the agent, broker, or web-broker, or other similar means or methods specified by HHS in guidance. * * * * *

(C) For enrollments for plan years beginning on or after January 1, 2028, including enrollments under Sec. 155.335(j), all documentation required under paragraph (j)(2)(iii)(A) of this section must be collected by having the consumer or the consumer's authorized representative take an action to execute an HHS-approved and -created consumer consent form. The action the consumer or the consumer's authorized representative took to provide consent must be clear to HHS. This may include hand-written or electronic written signature or initials on the HHS-approved and -created consumer consent form, an email from the consumer or the consumer's representative, or a recorded verbal conversation. A signature that is simply typed on the documentation or a filled-in check box does not properly indicate consent was provided by the consumer or the consumer's authorized representative. * * * * *

(3) Marketing requirements. An individual or entity described in paragraph (j)(1) of this section must additionally:

(i) Comply with the standards of conduct under paragraph (j)(2) of this section; and

(ii) Provide consumers with correct information, without omission of material fact, regarding the Federally-facilitated Exchanges, QHPs offered through the Federally-facilitated Exchanges, and insurance affordability programs, and refrain from marketing that is misleading, materially inaccurate, coercive, or discriminates based on race, color, national origin, disability, age, or sex.

(iii) Examples of prohibited misleading marketing practices agents, brokers, and web-brokers may not include in their marketing of FFE plans include, but are not limited to:

(A) Providing cash, monetary rebates, gift cards, travel vouchers, or cash equivalents as an inducement for enrollment or otherwise.

(B) Offering gifts to consumers, unless the gifts are of nominal value, are offered to similarly situated consumers without regard to whether or not the consumers enroll, and are not in the form of cash or cash equivalents.

(C) Falsely asserting or suggesting that consumers will always qualify for zero-dollar insurance/zero-dollar premiums.

(D) Falsely using identical or facsimiles of government or other official logos and notations.

(E) Miscommunicating enrollment timelines and deadlines.

(F) Misconstruing legislation, regulations, or Executive Orders, including listing fake or incorrect references or citations.

(G) Utilizing the image or likeness and/or utilize a quote from a notable figure, such as a celebrity or politician, in an advertisement claiming that figure has endorsed you or your agency when that endorsement is not truthful.

(iv) An individual or entity described in paragraph (j)(1) of this section must produce any marketing material upon request, within the specified timeframe HHS mandates, in response to monitoring, audit, and enforcement

activities conducted consistent with paragraphs (c)(5), (g), (h), and (k) of this section.

(v) An individual or entity described in paragraph (j)(1) of this section is responsible to ensure that all marketing-related materials created, written, released, or otherwise produced by the individual or entity or on their behalf adhere to the requirements of paragraphs (j)(3)(ii) and(iii) of this section, and to make all such marketing- related materials available upon request in accordance with paragraph (j)(3)(iv) of this section. * * * * *

Sec. 155.222 [Removed]

0 12. Remove Sec. 155.222.

0 13. Section 155.305 is amended by-- 0 a. Revising paragraph (f)(1)(ii) introductory text; 0 b. Adding paragraph (f)(1)(ii)(C); 0 c. Removing and reserving paragraph (f)(2); and 0 d. Revising paragraph (f)(4).

The revisions and addition read as follows:

Sec. 155.305 Eligibility standards.

* * * * *

(f) * * *

(1) * * *

(ii) One or more applicants who is expected to be a member of the tax filer's family within the meaning of 26 CFR 1.36B-1(d) for the benefit year-- * * * * *

(C) He or she is a U.S. citizen, U.S. national, or an eligible noncitizen as defined in Sec. 155.20. * * * * *

(4) Compliance with tax filing requirement--(i) APTC eligibility. (A) For plan year 2027, an Exchange must implement one of two policies where it may not determine a tax filer eligible for APTC if the tax filer and their spouse, if the tax filer is married, has either failed to file and reconcile for 1 year, as described in paragraph (f)(4)(ii)(A) of this section (“1 tax year FTR policy”) or has failed to file and reconcile for 2 consecutive tax years, as described in paragraph (f)(4)(ii)(B) of this section (“2 tax-year policy”). Exchanges must apply any such policy uniformly to all tax filers (and their spouses, if married).

(B) For plan year 2028 and beyond, an Exchange must implement a 1- tax year FTR policy described in paragraph (f)(4)(ii)(A) of this section.

(ii) Failure to file and reconcile. For purposes of paragraph (f)(4)(i) of this section:

(A) A tax filer and their spouse, if the tax filer is married, is considered to have failed to file and reconcile for 1 tax year if HHS notifies the Exchange as part of the process described in Sec. 155.320(c)(3) that APTC payments were made on behalf of either the tax filer or the tax filer's spouse, if the tax filer is a married couple, for the most recent year for which tax data would be utilized for verification of household income and family size in accordance with Sec. 155.320(c)(1)(i), and the tax filer or the tax filer's spouse did not comply with the requirement to file an income tax return for that year as required by 26 U.S.C. 6011, 6012, and in 26 CFR chapter I, and reconcile APTC for that period.

(B) A tax filer and their spouse, if the tax filer is married, is considered to have failed to file and reconcile for 2 tax years if HHS notifies the Exchange as part of the process described in Sec. 155.320(c)(3) that APTC payments were made on behalf of either the tax filer or the tax filer's spouse, if the tax filer is a married couple, for the 2 most recent consecutive tax years for which tax data would be utilized for verification of household income and family size in accordance with Sec. 155.320(c)(1)(i), and the tax filer or the tax filer's spouse did not comply with the requirement to file an income tax return for those years as required by 26 U.S.C. 6011, 6012, and in 26 CFR chapter I, and reconcile APTC for that period.

(iii) Notice Requirements. For purposes of paragraph (f)(4)(ii) of this section, the following notice requirements apply.

(A) An Exchange that implements a 2-tax year FTR policy as described in paragraph (f)(4)(ii)(B) of this section must:

(1) For tax filers failing to file and reconcile for 1 tax year as described in paragraph (f)(4)(ii)(A) of this section:

(i) Send a notification to the tax filer, consistent with the standards applicable to the protection of Federal Tax Information, that informs the tax filer that the Exchange has determined that the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file and reconcile, and educate the tax filer of the need to file and reconcile or risk being determined ineligible for APTC if they fail to file and reconcile for a second consecutive tax year; or

(ii) Send a notification to either the tax filer or their enrollee, that informs the tax filer or enrollee that they may be at risk of being determined ineligible for APTC in the future. These notices must educate tax filers or their enrollees on the requirement to file and reconcile, while not directly stating that the IRS indicates the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file and reconcile.

(2) For tax filers failing to file and reconcile for 2 consecutive tax years as described in paragraph (f)(4)(ii)(B) of this section:

(i) Send a direct notification to the tax filer, consistent with the standards applicable to the protection of Federal Tax Information, that explicitly informs the tax filer that the Exchange has determined that the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file their Federal income taxes and reconcile APTC, and educate the tax filer of the need to file and reconcile or risk being determined ineligible for APTC after 2 consecutive tax years of failing to file and reconcile; or

(ii) Send an indirect notification to either the tax filer or their enrollee, that informs the tax filer or enrollee that they may be at risk of being determined ineligible for APTC after 2 consecutive tax years of failing to file and reconcile. These notices must educate tax filers or their enrollees on the requirement to file and reconcile, while not directly stating that the Internal Revenue Service indicates the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file and reconcile.

(B) An Exchange that implements 1-tax year FTR policy as described in paragraph (f)(4)(ii)(A) of this section must:

(1) Send a notification to the tax filer, consistent with the standards applicable to the protection of Federal Tax Information, that informs the tax filer that the Exchange has determined that the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file and reconcile of the need to file and reconcile, and of the risk of being determined ineligible for APTC if they fail to file and reconcile immediately; or

(2) Send a notification to either the tax filer or their enrollee, that informs the tax filer or enrollee that they may be at risk of being determined ineligible for APTC in the future. These notices must educate tax filers or their enrollees on the requirement to file and reconcile, while not directly stating that the IRS indicates the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file and reconcile. * * * * *

0 14. Section 155.320 is amended by-- 0 a. Revising paragraphs (c)(3)(iii)(A) and (c)(3)(vi)(C)(2); 0 b. Removing the second occurrence of paragraph (c)(3)(viii); 0 c. Revising paragraphs (c)(3)(vii) and (viii); 0 d. Adding paragraph (c)(3)(ix); and

0 e. Removing paragraph (c)(5).

The revisions and addition read as follows:

Sec. 155.320 Verification process related to eligibility for insurance affordability programs.

* * * * *

(c) * * *

(3) * * *

(iii) * * *

(A) Except as specified in paragraphs (c)(3)(iii)(B), (C), and (D) of this section, if an applicant's attestation to projected annual household income, as described in paragraph (c)(3)(ii)(B) of this section, would qualify the tax payer as an applicable taxpayer under 26 CFR 1.36B-2(b) for the plan year for which coverage is requested and is more than a reasonable threshold above the annual household income computed in accordance with paragraph (c)(3)(ii)(A) of this section, the data described in paragraph (c)(3)(ii)(A) of this section indicates that projected annual household income is under 100 percent of the FPL, and the Exchange has not verified the applicant's MAGI-based income through the process specified in paragraph (c)(2)(ii) of this section to be within the applicable Medicaid or CHIP MAGI-based income standard, the Exchange must proceed in accordance with Sec. 155.315(f)(1) through (4). For the purposes of this paragraph, a reasonable threshold is established by the Exchange in guidance and approved by HHS, but must not be less than 10 percent, and can also include a threshold dollar amount. * * * * *

(vi) * * *

(C) * * *

(2) If the data described in paragraph (c)(3)(vi)(A) of this section indicates that projected annual household income is under 100 percent of the FPL and the applicant's attestation to projected household income, as described in paragraph (c)(3)(ii)(B) of this section, would qualify the taxpayer as an applicable taxpayer according to 26 CFR 1.36B-2(b) for the plan year for which coverage is requested and is more than a reasonable threshold above the annual household income as computed using data sources described in paragraph (c)(3)(vi)(A) of this section, in which case the Exchange must follow the procedures specified in Sec. 155.315(f)(1) through (4). The reasonable threshold used under this paragraph must be equal to the reasonable threshold established in accordance with paragraph (c)(3)(vi) of this section. * * * * *

(vii) Definition of household income. For the purposes of paragraph (c)(3) of this section, “household income” means household income as specified in 26 CFR 1.36B-1(e).

(viii) Definition of family size. For purposes of paragraph (c)(3) of this section, “family size” means family size as specified in section 26 CFR 1.36B-1(d).

(ix) Verification of eligible noncitizen status. (A) Verification with the records of the Department of Homeland Security. For an applicant who has information or documentation of immigration status that can be verified through the Department of Homeland Security's Systematic Alien Verification for Entitlements (SAVE) program, and who attests to having an eligible noncitizen immigration status as defined at Sec. 155.20, the Exchange must transmit information from the applicant or document to the Department of Homeland Security for verification.

(B) Inconsistencies and inability to verify information. For an applicant who attests to having an eligible noncitizen status as defined at Sec. 155.20, and for whom the Exchange cannot verify such attestation through the Department of Homeland Security, the Exchange must follow the procedures specified in Sec. 155.315(f)(1) through (4). The date on which the notice is received means 5 days after the date on the notice, unless the applicant demonstrates that he or she did not receive the notice within the 5 day period as described in Sec. 155.315(b)(2).

(C) If, at the conclusion of the period specified in paragraph (c)(3)(ix)(B) of this section, the Exchange remains unable to verify the applicant's attestation, the Exchange must determine the applicant ineligible for advance payments of the premium tax credit and cost- sharing reductions, notify the applicant of such determination in accordance with the notice requirements specified in Sec. 155.310(g), and discontinue any advance payments of the premium tax credit and cost-sharing reductions in accordance with the effective dates specified in Sec. 155.330(f). * * * * *

0 15. Section 155.400 is amended by revising paragraph (g) to read as follows:

Sec. 155.400 Enrollment of qualified individuals into QHPs.

* * * * *

(g) Premium payment threshold. Exchanges may, and the Federally- facilitated Exchanges and State-Based Exchanges on the Federal Platform will, allow issuers to implement, a premium payment threshold policy under which issuers can consider enrollees to have paid all amounts due if the enrollees pay an amount sufficient to maintain a percentage of total premium paid out of the total premium owed equal to or greater than a level prescribed by the issuer, provided that the level is reasonable and that the level and the policy are applied in a uniform manner to all enrollees. If an applicant or enrollee satisfies the premium payment threshold policy, the issuer may:

(1) Effectuate an enrollment based on payment of the binder payment under paragraph (e) of this section.

(2) Avoid triggering a grace period for non-payment of premium, as described by Sec. 156.270(d) of this subchapter or a grace period governed by State rules.

(3) Avoid terminating the enrollment for non-payment of premium as, described by Sec. Sec. 156.270(g) of this subchapter and 155.430(b)(2)(ii)(A) and (B). * * * * *

0 16. Section 155.420 is amended by-- 0 a. Removing paragraph (a)(4)(ii)(D); 0 b. Revising paragraph (a)(4)(iii) introductory text; 0 c. Removing paragraph (b)(2)(vii); 0 d. Revising paragraph (d)(13); 0 e. Removing paragraph (d)(16); and 0 f. Revising paragraph (g).

The revisions read as follows:

Sec. 155.420 Special enrollment periods.

(a) * * *

(4) * * *

(iii) For the other triggering events specified in paragraph (d) of this section, except for paragraphs (d)(2)(i), (d)(4), and (d)(6)(i) and (ii) of this section for becoming newly eligible or ineligible for CSRs, and paragraphs (d)(8), (9), (10), (12), and (14) of this section: * * * * *

(d) * * *

(13) At the option of the Exchange, the qualified individual provides satisfactory documentary evidence to verify his or her eligibility for an insurance affordability program or enrollment in a QHP through the Exchange following termination of Exchange enrollment due to a failure to verify such status within the time period specified in Sec. 155.315. * * * * *

(g) Special enrollment period verification. Beginning January 1, 2027, unless a request for modification is granted in accordance with Sec. 155.315(h), Exchanges on the Federal platform must conduct pre- enrollment verification of new applicants' eligibility for special enrollment periods under this section. An Exchange meets this requirement if it verifies eligibility each plan year for the number of individuals newly

enrolling in Exchange coverage through special enrollment periods that equals at least 75 percent of all special enrollments based on prior year enrollments. If the Exchange is unable to verify eligibility for individuals newly enrolling in Exchange coverage through a special enrollment period for which the Exchange requires verification, then such individuals are not eligible for enrollment through that special enrollment period. In accordance with Sec. 155.505(b)(1)(iii), individuals have the right to appeal the eligibility determination.

0 17. Section 155.605 is amended by-- 0 a. Removing “or” at the end of paragraph (d)(1)(ii) 0 b. Removing the period at the end of paragraph (d)(1)(iii) and adding “; or” in its place ; and 0 c. Adding new paragraph (d)(1)(iv).

The addition reads as follows:

Sec. 155.605 Eligibility standards for exemptions.

(d) * * *

(1) * * *

(iv) The applicant, or if the applicant is a tax dependent, the tax filer claiming the applicant as a dependent, has a projected household income that does not qualify them as an applicable taxpayer according to 26 CFR 1.36B-2(b) or does not qualify them for cost-sharing reductions according to 45 CFR 155.305(g)(1)(i)(C). * * * * *

0 18. Section 155.1050 is amended by-- 0 a. Revising the section heading and paragraphs (a)(1) and (2); and 0 b. Adding paragraph (d).

The revisions and addition read as follows:

Sec. 155.1050 Establishment of Exchange provider access standards.

(a) * * *

(1) A Federally-facilitated Exchange State without an Effective Provider Access Review Program (as defined in paragraph (d) of this section) must ensure that each QHP provides sufficient access to providers in a manner that meets the standards specified in Sec. 156.230 for network plans, or, for plan years beginning on or after January 1, 2028, Sec. 156.236 for non-network plans if such plans are allowed to be offered through the Exchange, as applicable. A State on the Federally-facilitated Exchanges with an Effective Provider Access Review Program (as defined in paragraph (d) of this section) must ensure that each QHP provides sufficient access to providers in a manner that meets the standards specified in Sec. 156.230(a)(1) for network plans, or, for plan years beginning on or after January 1, 2028, Sec. 156.236(a) for non-network plans if such plans are allowed to be offered through the Exchange, as applicable.

(2) State Exchanges and State-based Exchanges on the Federal Platform must ensure that each QHP provides sufficient access to providers in a manner that meets standards under Sec. 156.230(a)(1)(ii) and (iii) for network plans, or, for plan years beginning on or after January 1, 2027, Sec. 156.236(a) for non-network plans if such plans are allowed to be offered through the Exchange, as applicable. * * * * *

(d)(1) FFE States may elect to conduct their own provider access certification reviews of issuers' plans, with or without a provider network, applying for certification as a QHP to be offered through a Federally-facilitated Exchange provided that the State has demonstrated sufficient authority and the technical capacity to conduct these reviews by satisfying the applicable criteria to be considered to have an Effective Provider Access Review Program under paragraphs (d)(2) through (d)(4) of this section. This option applies to Federally- facilitated Exchange States, including States performing plan management. If States do not satisfy the criteria established under paragraphs (d)(2) through (d)(4) of this section, or do not elect to conduct such reviews, CMS will continue to conduct reviews of QHP issuer provider access in those States consistent with requirements listed under Sec. 156.230 for network plans and under Sec. 156.236 for non-network plans. Applicable requirements for non-network plans under this section are effective for plan years beginning on or after January 1, 2028.

(2) Federally-facilitated Exchange States with an Effective Provider Access Review Program must ensure that a QHP issuer that uses a network of providers ensures that the in-network providers, as available to all enrollees, include essential community providers (ECPs) in accordance with Sec. 156.235, and maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay. The QHP issuer's provider network consisting of in-network providers, as available to all enrollees, must be consistent with the rules for network plans of section 2702(c) of the PHS Act.

(3) Federally-facilitated Exchange States with an Effective Provider Access Review Program must ensure that a QHP issuer that does not use a network of providers (a non-network plan) provides access to a sufficient choice of providers that accept the non-network plan's benefit amount as payment in full, including ECPs and providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay.

(4) A Federally-facilitated Exchange State that elects to conduct provider access reviews has an Effective Provider Access Review Program if it meets the following requirements:

(i) The State has established provider access standards that are set forth in State statute or regulation, which are consistent with provider access standards as set forth in Sec. 156.230(a)(1)(ii) and (iii), and reports to CMS whether the State has delegated authority to some entity other than the State Department of Insurance to perform any or all provider access review activities.

(ii) The State's provider access review process includes reporting systems for State required provider access metrics and documentation of methodology and the State provides descriptions of all data collection systems, resources, templates, and methodologies used by the State, or the State's delegated entity to collect and review provider access data; and the State receives from issuers data and documentation in connection with provider access standards that are sufficient to conduct the examination.

(iii) The State's provider access review process includes procedures to ensure full and ongoing compliance with State provider access standards and enforcement frameworks applicable to issuers that fail to meet provider access standards so that those issuers come into compliance with State provider access standards, including standardized processes to assess efforts the issuer is pursuing to come into compliance with State provider access standards and implementing any justification and exception processes for issuers that have not yet or cannot meet provider access requirements.

(iv) The State establishes and maintains clear procedures and timeline requirements for regular provider access reviews, including processes that ensure reviews occur prior to completion of each plan year's QHP certification cycle.

(v) The State has a process for monitoring and addressing consumer- related provider access complaints to ensure sufficient access to providers consistent with section 1311(c)(1)(B) of the Affordable Care Act and as set forth in State statute.

(vi) The State has a process to collect and review information described under Sec. 156.236(b)(4) through (b)(9) from non-network plans, which non-network plans must submit to the FFE for a determination that it provides access to a sufficient choice of providers that accept the non-network plan's benefit amount as payment in full.

(5) CMS will determine whether a State has an Effective Provider Access Review Program based on information available to CMS that demonstrates whether the program meets the criteria described under paragraphs (d)(2) through (d)(4) of this section.

(6) CMS may grant an exception to the requirements in paragraph (d) of this section if it determines that making such an exception is in the interests of qualified individuals in the State or States in which such Exchange operates.

(7) CMS will notify the FFE State electing to conduct provider access certification reviews of its decision in writing whether the State is determined to have an Effective Provider Access Review Program and can therefore conduct its own provider access certification reviews. CMS reserves the right to evaluate at any time whether, and to what extent, an FFE State's circumstances have changed such that it has begun to or has ceased to satisfy the criteria established by CMS under this section. Such evaluations may result in CMS assuming provider access review responsibilities or transitioning such responsibilities back to the State. * * * * *

0 19. Add Sec. 155.1051 to subpart K to read as follows:

Sec. 155.1051 Effective Essential Community Provider Review Program.

(a) FFE States may elect to conduct their own ECP certification reviews of issuers' plans with or without a provider network applying for certification as a QHP to be offered through a Federally- facilitated Exchange provided that the State demonstrates it has sufficient authority and the technical capacity to conduct these reviews by satisfying the applicable criteria to be considered to have an Effective Essential Community Provider Review Program under this section. This option applies to all FFE States, including States performing plan management. An FFE State must demonstrate it meets applicable criteria established under paragraphs (b) through (c) of this section for both network plans and non-network plans, and the sufficient authority and technical capacity to conduct reviews of such plans (as assessed by CMS under Sec. 155.1051(e)), to be considered to have an Effective Essential Community Provider Review Program, if they decide to certify such plans. If FFE States do not satisfy the criteria established by CMS under paragraphs (b) through (e) of this section or do not elect to conduct such reviews, then CMS will continue to perform ECP certification reviews consistent with Sec. 156.235 for network plans and Sec. 156.236 for non-network plans. Applicable requirements for non-network plans under this section are effective for plan years beginning on or after January 1, 2028.

(b) FFE States with an Effective ECP Review Program must ensure that a QHP issuer with a provider network includes in their provider network a sufficient number and geographic distribution of ECPs, where available, to ensure reasonable and timely access to a broad range of such providers for low-income individuals or individuals residing in Health Professional Shortage Areas within the QHP's service area, in accordance with the Exchange's network adequacy standards. FFE States with an Effective ECP Review Program must also ensure that a non- network plan applying for certification to be offered as a QHP through a Federally-facilitated Exchange demonstrates that it provides reasonable and timely access to ECPs that accept the plan's benefit amount as payment in full to ensure that services will be accessible without unreasonable delay.

(c) FFE States with an Effective ECP Review Program must have established ECP requirements that are set forth in State statute or regulation. FFE States must demonstrate that these established ECP requirements ensure that plans meet all the following requirements that promote a sufficient number and geographic distribution of ECPs:

(1) The minimum percentage requirements under Sec. 156.235(a)(2)(i) for network plans, and under Sec. 156.236(b)(1) for non-network plans.

(2) The Indian health care provider requirement under Sec. 156.235(a)(2)(ii)(A) for network plans and under Sec. 156.236(b)(3) for non-network plans.

(3) The category per county requirements, including for each of the eight ECP category types under Sec. 156.235(a)(2)(ii)(B) for network plans and under Sec. 156.236(b)(2) for non-network plans.

(d) FFE States with an Effective ECP Review Program that have alternative ECP requirements compared to those described under paragraph (c)(1) through (3) of this section must demonstrate how their requirements would continue to promote a sufficient number and geographic distribution of ECPs to ensure reasonable and timely access to ECPs, and an adequate level of service for low-income enrollees or individuals residing in Health Professional Shortage Areas.

(e) CMS will consider all the following factors in its review to determine if an FFE State has an Effective ECP Review Program:

(1) The State's legal authority to review whether plans applying for QHP certification meet ECP requirements, including relevant State regulations and statutes.

(2) Evidence that the State's requirements are consistent with ECP requirements under paragraph (c)(1) through (3) of this section that promote a sufficient number and geographic distribution of ECPs, or the State provides a rationale to describe how its alternative requirements promote a sufficient number and geographic distribution of ECPs to ensure reasonable and timely access to ECPs.

(3) A description of the State's definition of an ECP, if different from the definition under Sec. 156.235(c), including relevant categories and eligibility criteria that the State uses to determine whether a facility qualifies as an ECP.

(4) Whether the State utilizes the Federal ECP List or has a process it uses to identify qualified ECPs that may be included within a network plan's provider network.

(5) Whether the State utilizes the Federal ECP List or has a process it uses to identify qualified ECPs that may accept a non- network plan's benefit amount as payment in full.

(6) A description of data collection systems, resources, templates, or methodologies used by the State to collect and review ECP data.

(7) Whether the State generally collects information from QHP issuers regarding the status of contract offers for network plans or offers of benefit amounts as payment in full to an ECP for non-network plans.

(8) Whether the State has delegated authority to some other entity other than the State Department of Insurance to perform any or all ECP review activities.

(9) Whether the State has compliance reviews, follow-up procedures, and enforcement frameworks applicable to issuers that demonstrate inadequate networks of ECPs or inadequate access to ECPs that accept benefit amounts as payment in full, so that those issuers come into compliance with State ECP requirements, including standardized processes to assess efforts the issuer is pursuing to come into compliance with State ECP requirements and any justification and exception processes for

issuers that have not yet or cannot meet ECP requirements.

(10) Whether the State has a process for monitoring and addressing consumer-related complaints regarding access to ECPs to ensure sufficient access to ECPs consistent with section 1311(c)(1)(C) of the Affordable Care Act and set forth in State statute.

(11) Whether the State collects the information described under Sec. 156.236(b)(4) through (b)(9) from issuers of non-network plans, which issuers of non-network plans must submit to the FFE for a determination that the plan provides reasonable and timely access to ECPs that accept the plan's benefit amount as payment in full.

(f) CMS will notify the FFE State electing to conduct ECP certification reviews of its decision in writing whether the State is determined to have an Effective ECP Review Program and can therefore conduct its own ECP certification reviews. CMS reserves the right to evaluate at any time whether, and to what extent, an FFE State's circumstances have changed such that it has begun to or has ceased to satisfy the criteria established by CMS under this section, and consequently no longer has an Effective ECP Review Program.

0 20. Section 155.1200 is amended by revising paragraph (d) introductory text and adding paragraph (e) to read as follows:

Sec. 155.1200 General program integrity and oversight requirements.

* * * * *

(d) External audit standard. The State Exchange must ensure that independent audits of State Exchange financial activities and program activities under paragraph (c) of this section address the following requirements, unless a State Exchange is satisfying certain programmatic audit requirements for a given benefit year, as identified by HHS in sub-regulatory guidance, under paragraph (e) of this section: * * * * *

(e) State Exchange Improper Payment Measurement (SEIPM) program. For a given benefit year, a State Exchange may satisfy certain requirements of the independent external programmatic audit, particularly the review of compliance with subparts D and E of this part, as identified by HHS in sub-regulatory guidance, as outlined in paragraph (d) of this section, by completing the SEIPM process established through 45 CFR part 155, subpart Q. * * * * *

0 21. Add subpart Q to read as follows:

Subpart Q--State Exchange Improper Payment Measurement (SEIPM)

Sec. 155.1600 Purpose and scope. 155.1605 Applicability date and implementation. 155.1610 Definitions. 155.1615 Information submission. 155.1620 Sampling procedures. 155.1625 Determining payment errors. 155.1630 Difference Resolution and appeal process. 155.1635 Corrective action plan (CAP). 155.1640 SEIPM preparation phase. 155.1645 Minimizing potential duplicate audit requirements. 155.1650 Failure to comply.

Sec. 155.1600 Purpose and scope.

(a) This subpart sets forth the requirements of the State Exchange Improper Payment Measurement (SEIPM) program. SEIPM is an initiative through which HHS will measure improper payments of advance payment of the premium tax credit (APTC) that are administered by State Exchanges, as described in more detail in Sec. 155.1610. HHS will use the SEIPM program results to produce an estimate of improper payments of APTC aggregated across State Exchanges.

(b) Unless otherwise specified by HHS, all State Exchanges must submit information on an annual basis that is necessary to support the SEIPM processes.

(c) HHS will publish in the Agency Financial Report an estimate of improper payments that is aggregated across all State Exchanges.

Sec. 155.1605 Applicability date and implementation.

(a) Applicability date. The requirements of this subpart are applicable beginning January 1, 2027.

Sec. 155.1610 Definitions.

As used in this subpart--

Annual Program Schedule means the document issued by HHS to each State Exchange that prescribes the dates by which key program milestones must be met for each SEIPM Cycle.

Administrative Appeal means the process by which a State Exchange may request HHS to review and reconsider a Difference Resolution Decision. The appeal is the second and last level for a State Exchange to contest findings of error or improper payment as it relates to APTC.

Administrative Appeal Decision means the HHS final appeal decision resulting from a State Exchange's request for an appeal of one or more error or improper payment findings in a Sampled Unit Assessment Package.

Corrective Action Plan (CAP) means the plan a State Exchange develops in order to correct errors resulting in improper payments of APTC identified through SEIPM.

Difference Resolution means the process by which a State Exchange may initially request HHS to reconsider one or more errors or improper payment findings documented in a Sampled Unit Assessment Package.

Difference Resolution Decision means the HHS decision resulting from a State Exchange's request for a difference resolution of any Sampled Unit Assessment Package.

Error means a finding by HHS that a State Exchange did not correctly apply a requirement of subparts D and E of this part related to:

(1) Eligibility for and enrollment in a Qualified Health Plan (QHP);

(2) Eligibility for APTC, and calculated amount of APTC;

(3) Redeterminations of eligibility during a plan year;

(4) Eligibility redeterminations for purposes of re-enrollment.

Measurement Year means the calendar year in which the processes described in Sec. 155.1625 are initiated. The Measurement Year immediately follows the Plan Year and is the second year of the SEIPM Cycle.

Reporting Year means the calendar year in which HHS reports the improper payment rate for State Exchanges as required under Sec. 155.1625(c), following completion of the measurement processes for the applicable Plan Year. The Reporting Year immediately follows the Measurement Year and is the last year of the SEIPM Cycle.

Sampled Unit Assessment Package means the collection of findings and supporting documentation that HHS prepares in order to record errors at the tax household level using the process described in Sec. 155.1625.

State Exchange Improper Payment Measurement or SEIPM means the process for determining estimated improper payments of APTC that are administered by State Exchanges as required under the Payment Integrity Information Act of 2019, which includes a review of a State Exchange's APTC-related determinations regarding:

(1) Eligibility for and enrollment in a QHP;

(2) Eligibility for APTC, and calculated amount of APTC;

(3) Redeterminations of eligibility during a Plan Year;

(4) Annual eligibility redeterminations.

SEIPM Cycle means the 3-year period consisting of the Plan Year, Measurement Year, and Reporting Year, during which the improper payment measurement process occurs for the Plan Year that is subject to review.

Tax household means the applicant, the applicant's spouse if the applicant is married and files a joint return, and all individuals who are dependents of the applicant or spouse as defined in 26 U.S.C. 152.

Sec. 155.1615 Information submission.

(a) HHS will issue an Annual Program Schedule to each State Exchange no later than January 5th of the Measurement Year. The Annual Program Schedule will specify the deadlines for all information submissions required under this section.

(b) On an annual basis, each State Exchange must submit or make available to HHS the following information:

(1) Program documentation. Policy, operational and technical documentation concerning business rules and APTC calculations that pertain to consumer eligibility and enrollment processes of the State Exchange as well as information that describes the data system architecture of the State Exchange such as entity relationship diagrams and data dictionaries.

(2) Universe. For the Plan Year being reviewed, a listing of the population of tax households that have associated QHP enrollments and payments of APTC. For each tax household within the universe, the State Exchange must submit the following information:

(i) Exchange assigned policy identifier;

(ii) Tax household grouping identifier;

(iii) SSN inconsistency indicator;

(iv) Citizenship inconsistency indicator;

(v) Lawful presence inconsistency indicator;

(vi) Annual income inconsistency indicator;

(vii) Non-employer sponsored minimum essential coverage inconsistency indicator;

(viii) Employer sponsored minimum essential coverage inconsistency indicator;

(ix) Incarceration inconsistency indicator;

(x) Residency inconsistency indicator;

(xi) Number of tax household members; and

(xii) APTC amount paid over the duration of the benefit year.

(3) Tax household Data. For each of the sampled tax households and in a format specified by HHS:

(i) Information pertaining to the calculation of the APTC benefits paid that includes monthly enrollment premium amounts, monthly APTC payment amounts, monthly Second Lowest Cost Silver Plan Premium amounts, and the amount of each monthly premium that is attributable to essential health benefits.

(ii) Information relevant to enrollment that includes dates and amounts of effectuation payments, premium payment amount, and policy start and end dates.

(iii) Information relevant to the determination of eligibility for a special enrollment period (where applicable), which would include (where applicable) information collected by the State Exchange about consumer attestations and representations regarding special enrollment period eligibility criteria, copies of documentary evidence submitted by applicants, electronic verification information, and timing information.

(iv) Information about the timing of QHP certification or approval, the coverage area of the associated QHP, and the timing of any QHP decertification or suppression.

(v) To the extent applicable, for each person who is included in the APTC payment calculation:

(A) Information collected by the State Exchange about consumer attestations regarding QHP and APTC eligibility factors and demographic information relevant to initial QHP enrollment and eligibility.

(B) APTC eligibility and payment determinations which includes evidence of required data verifications, the electronic sources consulted, the timing of required verifications, and the results of the verification.

(C) Information relevant to QHP and APTC manual eligibility verifications and the resolution of electronic verification inconsistencies, which would include copies of documentary evidence submitted by QHP enrollees, the timing of submissions, the timing of adjudication, and information about good faith extensions.

(D) Information relevant to QHP and APTC eligibility redeterminations such as information about automatic annual redeterminations, the timing and results of periodic examinations of data sources, and policy or application changes initiated by the consumer and resultant electronic or manual eligibility verifications.

(vi) Any consumer submitted documents that were used to establish new or continued eligibility for enrollment in a QHP and APTC.

Sec. 155.1620 Sampling procedures.

(a) Sample size. At the beginning of each SEIPM cycle, HHS will calculate a sample size in aggregate across all State Exchanges.

(1) Statistical methodology. The sample size will be calculated to estimate an improper payment rate.

(2) State-specific sample sizes. HHS will develop sample sizes specific for each State Exchange. HHS may take into consideration the following factors in determining each State Exchange's sample size for the current SEIPM cycle:

(i) Overall APTC expenditures associated with the State Exchange.

(ii) State-level precision goals for the current SEIPM cycle.

(iii) The improper payment rate from the State Exchange's previous SEIPM cycle.

(3) Sample size parameters. HHS will establish minimum and maximum sample sizes to ensure statistical validity while maintaining operational feasibility across State Exchanges of varying sizes.

(b) Sample selection procedures. On an annual basis, HHS will select samples of tax households from the data provided by each State Exchange as described in Sec. 155.1615(b)(2).

(c) State Exchange coordination and notification--(1) Sampled records notification. Following receipt of the universe data from State Exchanges as described in Sec. 155.1615(b)(2), HHS will notify each State Exchange of the specific records selected for review. This notification will include:

(i) The total number of sampled tax households selected for the State Exchange.

(ii) A unique identifier for each sampled tax household.

(iii) Any specific instructions or requirements that HHS determines are needed to facilitate HHS' review of the sampled records.

(2) Timing of sampled records notification. HHS will provide the sampled records notification described in paragraph (c)(1) of this section no later than 60 days after receipt of complete universe data from all State Exchanges.

(3) Extension of sampling notification timeline. (i) HHS may extend the 60-day timeline specified in paragraph (c)(2) of this section if:

(A) Technical issues prevent completion of the sampling process within the standard timeframe;

(B) Data quality issues require additional coordination with State Exchanges before sampling can be completed; or

(C) Other circumstances beyond HHS's control necessitate additional time to ensure accurate sampling methodology.

(ii) If HHS determines an extension is necessary, HHS will:

(A) Notify all affected State Exchanges in writing of the extension and the revised notification date;

(B) Provide the reason for the extension; and

(C) Confirm the impact, if any, on subsequent SEIPM cycle timelines.

Sec. 155.1625 Determining payment errors.

(a) Review of records and error identification. (1) Systematic review process. For each sampled record, HHS will conduct a comprehensive review of all information provided by the State Exchange using standardized review criteria.

(2) Data sources. HHS will conduct reviews using the tax household information provided under Sec. 155.1615(b)(3), supplemented by any relevant consumer-submitted documents that were gathered by the State Exchange as part of the enrollment and eligibility process and provided to HHS.

(3) Error identification. The review will identify whether the State Exchange made any errors related to the following resulting in improper payments of APTC:

(i) Enrolling or re-enrolling a consumer into a QHP for which APTC was paid.

(ii) Consumer eligibility for APTC being paid on the consumer's behalf.

(iii) Calculating the APTC amount that was paid on the consumer's behalf.

(iv) Taking required actions upon changes to a consumer's status that would affect their APTC-related eligibility or payment amount.

(4) Review standards and criteria. HHS will apply consistent review standards based on the APTC-related determination requirements established in subparts D and E of this part, and other applicable provisions of this part.

(b) Error evaluation. HHS will evaluate each error to determine an improper payment amount. For each error identified, HHS will:

(1) Calculate the correct APTC amount based on the requirements of section 36B of the Internal Revenue Code and applicable implementing regulations.

(2) Determine an improper payment amount.

(3) Document the error and improper payment amount within a Sampled Unit Assessment Package and provide the Sampled Unit Assessment Package to the State Exchange.

(4) Extrapolate the identified improper payments from the sample to estimate the total improper payment amount for the State Exchange's entire universe of APTC payments, using statistically valid methodologies that comply with OMB guidance on improper payment estimation.

(c) Reporting. HHS will report annually in the Agency Financial Report, which is made available to the public:

(1) The estimated aggregate improper payment rate for Federal and State Exchanges combined.

(2) The estimated aggregate improper payment rate for State Exchanges, and;

(3) HHS will provide to each State Exchange a report that documents the State-specific improper payment rate and error analysis.

Sec. 155.1630 Difference Resolution and appeal process.

(a) Difference Resolution. (1) The State Exchange may make a written Difference Resolution request to HHS within 30 days after the issuance of the Sampled Unit Assessment Package to dispute HHS' error and improper payment findings.

(2) Upon receipt of a Difference Resolution request, HHS will do the following:

(i) Engage with the State Exchange in a collaborative process to examine the disputed findings and any additional documentation provided by the State Exchange.

(ii) Evaluate the disputed findings by applying the same protocol used in the original review while considering whether the State Exchange's position is supported by the existing or newly provided evidence.

(iii) Prepare the Difference Resolution Decision.

(3) The Difference Resolution Decision will be communicated to the State Exchange within 90 days of receipt of the written request for a Difference Resolution. The Difference Resolution Decision will include a summary of the analysis and rationale that informed the decision.

(b) Administrative appeal. (1) To dispute a Difference Resolution Decision, the State Exchange may make a written request for an administrative appeal within 15 business days after the issuance of the Difference Resolution Decision.

(i) The State Exchange may not submit new evidence; it may use evidence that was previously submitted during Difference Resolution.

(ii) The State Exchange may provide additional context regarding information that was submitted during Difference Resolution.

(2) Upon receipt of an appeal request, HHS will do the following:

(i) Assign the appeal request to one or more administrative appeal reviewers who were not involved in the original review;

(ii) Conduct a comprehensive review of the disputed findings using the administrative record established during the Difference Resolution process;

(iii) Independently evaluate the disputed findings by applying the same protocol used in the original review while considering whether the State Exchange's position is supported by the evidence; and

(iv) Prepare an appeal decision for the completed review based on a preponderance of the evidence.

(3) HHS will issue the appeal decision within 90 days of receipt of the written request for appeal. The appeal decision will include a summary of the analysis and rationale that informed the decision.

(c) Difference Resolution and administrative appeal submission requirements. All Difference Resolution and appeal requests must be filed in a form and manner specified by HHS and contain the following:

(1) A clear statement of the specific finding(s) being challenged.

(2) All factual and legal bases for filing the request.

(3) Evidence directly related to the finding(s), which may include:

(i) Clarifying information regarding data interpretation.

(ii) Legal citations supporting the State Exchange's position.

(d) Timing of Difference Resolution and Administrative Appeal decisions. (1) For Difference Resolution Requests or administrative appeals resolved in favor of the State Exchange during the current SEIPM cycle:

(i) HHS will adjust the affected improper payment rate calculations for the SEIPM cycle.

(ii) Updated aggregate rates will be reflected in current cycle reporting.

(2) For Difference Resolution Requests or administrative appeals resolved in favor of the State Exchange after completion of the SEIPM cycle:

(i) If Difference Resolution or administrative appeal decisions result in material changes to aggregate rates, HHS will publish amended aggregate improper payment rates in subsequent Agency Financial Reports or other appropriate public reporting mechanisms as well as notify affected State Exchanges of any amendments to previously published rates.

(ii) If HHS determines, at its discretion, that the Difference Resolution or administrative appeal decisions do not result in material changes to aggregate rates, no action will be taken to publish amended aggregated improper payment rates or notify affected State Exchanges.

(e) Good cause exception. For good cause, HHS may extend the timelines

for accepting a Difference Resolution request or administrative appeal request or for issuing a Difference Resolution Decision or Administrative Appeal Decision. The failure of HHS to timely issue a Difference Resolution or Administrative Appeal decision does not indicate an acceptance of the State Exchange's position and is not a basis to decide in favor of the State Exchange.

Sec. 155.1635 Corrective action plan (CAP).

(a) CAP. HHS may require the State Exchange to develop and submit a proposed CAP to correct errors resulting in improper payments.

(b) Development of proposed CAP. A State Exchange's proposed CAP must address errors that are included in the State Exchange improper payment report described in Sec. 155.1625(c)(2) and must be developed in accordance with HHS requirements.

(1) In developing a proposed CAP, the State Exchange must conduct an error analysis such as reviewing causes, characteristics, and frequency of errors that are associated with improper payments. The State Exchange must review the findings of the analysis to determine the causes of the errors included in the State Exchange improper payment rate, if any, and to identify the root causes of the resulting improper payments.

(i) If a State Exchange has a pending Difference Resolution request or administrative appeal and HHS requests a CAP, HHS may provide a new timeline for CAP submission after the Difference Resolution or Administrative Appeal Decision and calculation of the final improper payment rate.

(2) The State Exchange must determine the corrective actions to be implemented to correct causes of the errors included in the State Exchange improper payment rate and to prevent them from occurring again.

(3) The proposed CAP must include measurable milestones, accountability mechanisms, regular monitoring and validation of progress, documentation of implemented corrective actions, and regular status updates. The CAP must include all the following for each identified error:

(i) The specific corrective action.

(ii) Status of the corrective action.

(iii) Scheduled or actual implementation date of the corrective action.

(iv) Key personnel responsible for implementing each corrective action.

(v) A plan for monitoring the effectiveness of the corrective action.

(c) Implementation and evaluation of a CAP. A State Exchange must develop an implementation schedule for its CAP, implement the plan in accordance with that schedule, and regularly evaluate whether the initiatives are effective at reducing or eliminating error causes. The State Exchange must provide updates on CAP implementation progress in a manner and frequency specified by HHS, but at least annually.

(d) Failures in the CAP process. If a State Exchange does not submit a CAP when one has been required, submits an incomplete CAP that does not address all the required parts of a CAP as specified in paragraph (b)(3) of this section, fails to follow the implementation schedule referenced in paragraph (c), or submits a CAP that is otherwise unacceptable following technical assistance from HHS, HHS may take actions consistent with Sec. 155.1650.

Sec. 155.1640 SEIPM preparation phase.

(a) Any State Exchange in its first year of operation must participate in a 1-year SEIPM preparation phase prior to participating in SEIPM in the subsequent year.

(b) To satisfy the requirements of the SEIPM preparation phase, a State Exchange must:

(1) Complete the information submission requirements in Sec. 155.1615(b)(1) and (3) using information from the most current Plan Year for a sample size not to exceed 10 unique tax households that address scenarios specified by HHS.

(2) Undergo the review procedures in Sec. 155.1625(a) and (b).

(3) Participate in technical assistance activities provided by HHS, which may include:

(i) Training on SEIPM requirements and procedures;

(ii) System readiness assessments;

(iii) Data quality validation exercises; and

(iv) Process improvement recommendations.

(c) At the beginning of each calendar year, HHS will provide any State Exchange that meets the conditions in paragraph (a) of this section with a schedule that spans a 12-month period that specifies when the requirements of this section must be completed.

Sec. 155.1645 Minimizing potential duplicate audit requirements.

HHS will minimize potential duplicate requirements of the annual independent external programmatic audit described at Sec. 155.1200(c) and (d) and SEIPM, such that, as determined by HHS, a State Exchange may be deemed to satisfy certain requirements of Sec. 155.1200(c) and (d), particularly the review of compliance with subparts D and E, as identified in HHS sub-regulatory guidance, for a particular plan year by successfully completing the SEIPM process.

Sec. 155.1650 Failure to comply.

(a) General principle. For purposes of improper payment measurement under this subpart, HHS will classify APTC payments as improper when a State Exchange fails to provide adequate documentation demonstrating that such payments were made in accordance with applicable Federal requirements.

(b) Determination of substantial noncompliance. HHS will determine that a State Exchange has failed to substantially comply with this subpart if the State Exchange:

(1) Fails to submit required data or documentation within the timelines specified in the Annual Program Schedule.

(2) Submits data or documentation that is incomplete, inaccurate, or in a format that would reasonably prevent effective review.

(3) Fails to implement the CAP process as set out in Sec. 155.1635(d).

(4) Demonstrates a pattern of more than five instances during a SEIPM cycle in which the State Exchange fails to respond within 30 calendar days, or provides a non-responsive answer, to HHS requests for clarification or additional information.

(c) Notice and opportunity to cure. Before implementing measures under paragraph (d) of this section, HHS will:

(1) Provide written notice to the State Exchange specifying the nature of the noncompliance and the potential consequences.

(2) Allow the State Exchange a reasonable opportunity, not less than 30 days, to cure the noncompliance or demonstrate that compliance has been achieved.

(d) Remedial measures. If a State Exchange fails to substantially comply with the data collection requirements, the CAP provisions contained in this subpart, or HHS requests for clarification or additional information, and HHS finds that such failures undermine or prohibit HHS's efficient administration of Exchange improper payment measurement activities, HHS may implement measures or procedures for:

(1) Enhanced monitoring and reporting.

(2) Mandatory implementation of specific operational procedures or controls.

(3) On-site visits to State Exchange facilities to assess operational procedures, data systems, and compliance with program requirements.

(e) Escalation procedures. If a State Exchange continues to fail to comply after implementation of initial remedial measures under paragraph (d) of this section, HHS may initiate proceedings to revoke the State Exchange's authority to operate in accordance with applicable law.

PART 156--HEALTH INSURANCE ISSUER STANDARDS UNDER THE AFFORDABLE CARE ACT, INCLUDING STANDARDS RELATED TO EXCHANGES

0 22. The authority citation for part 156 continues to read as follows:

Authority: 42 U.S.C. 18021-18024, 18031-18032, 18041-18042, 18044, 18054, 18061, 18063, 18071, 18082, and 26 U.S.C. 36B.

0 23. Section 156.115 is amended by-- 0 a. Redesignating paragraphs (a)(2) through (a)(6) as paragraphs (a)(3) through (a)(7); 0 b. Adding new paragraph (a)(2); and 0 c. Revising paragraph (d).

The addition and revision read as follows:

Sec. 156.115 Provision of EHB.

(a) * * *

(2) Are required by a State action taking place on or before December 31, 2011. * * * * *

(d) For plan years beginning before January 1, 2026, an issuer of a plan offering EHB may not include routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, or non-medically necessary orthodontia as EHB. For plan years beginning on any day in calendar year 2026, an issuer of a plan offering EHB may not include routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/ custodial nursing home care benefits, non-medically necessary orthodontia, or specified sex-trait modification procedures (as defined at Sec. 156.400) as EHB. For plan years beginning on or after January 1, 2027, an issuer of a plan offering EHB may not include routine non- pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, non-medically necessary orthodontia, or specified sex-trait modification procedures (as defined at Sec. 156.400) as EHB. * * * * *

0 24. Section 156.130 is amended by revising paragraph (a)(2) to read as follows:

Sec. 156.130 Cost-sharing requirements.

(a) * * *

(2) Except as permitted in Sec. 156.136 and Sec. 156.155(a)(3)(ii), for a plan year beginning in a calendar year after 2014, cost sharing may not exceed the following: * * * * *

0 25. Add Sec. 156.136 to subpart B to read as follows:

Sec. 156.136 Expanded cost-sharing parameters.

For plan years beginning on or after January 1, 2027, if an issuer offers a bronze plan (as defined at Sec. 156.140(b)(1)) in the individual market that complies with the cost-sharing requirements at Sec. 156.130 and the levels of coverage requirements at Sec. 156.140, the issuer may also offer within the same service area bronze plans that exceed the maximum annual limitation on cost sharing at Sec. 156.130 by amounts in increments of 50 dollars in order to achieve an AV within the standard bronze de minimis variation at Sec. 156.140(c), calculated as described in Sec. 156.135 of this subpart, but not to exceed an amount equal to 130 percent of the annual limitation on cost sharing under section 1302(c)(1) of the Affordable Care Act.

0 26. Section 156.155 is amended by-- 0 a. Revising paragraph (a)(3); and 0 b. Adding paragraph (a)(6).

The revision and addition read as follows:

Sec. 156.155 Enrollment in catastrophic plans.

(a) * * *

(3)(i) For plan years beginning before January 1, 2028, provides coverage of the essential health benefits under section 1302(b) of the Affordable Care Act, except that the plan provides no benefits for any plan year (except as provided in paragraphs (a)(4), (b), and (c) of this section) until the annual limitation on cost sharing in section 1302(c)(1) of the Affordable Care Act is reached.

(ii) For plan years beginning on or after January 1, 2028, provides coverage of the essential health benefits under section 1302(b) of the Affordable Care Act, except that the plan provides no benefits for any plan year (except as provided in paragraphs (a)(4) and (6), (b), and (c) of this section) until an amount equal to 130 percent of the annual limitation on cost sharing in section 1302(c)(1) of the Affordable Care Act, rounded down to the next lowest multiple of 50 dollars, is reached. * * * * *

(6) For plan years beginning on or after January 1, 2027, has a plan term of either 1 plan year, or of multiple consecutive plan years not to exceed 10 plan years. Such a plan with a plan term of at least 2 consecutive plan years may utilize value-based insurance designs to provide benefits before reaching the deductible, pursuant to guidelines issued by the Secretaries of Health and Human Services, Labor, and the Treasury under section 2713(c) of the Public Health Service Act. * * * * *

Sec. 156.201 [Removed]

0 27. Remove Sec. 156.201.

Sec. 156.202 [Removed]

0 28. Remove Sec. 156.202.

0 29. Section 156.230 is amended by revising the section heading, paragraphs (a)(1) introductory text, (a)(2)(i) introductory text, (a)(2)(ii), and (a)(3) and (4) to read as follows:

Sec. 156.230 Provider access standards for network plans.

(a) * * *

(1) A QHP that uses a network of providers must ensure that the provider network consisting of in-network providers, as available to all enrollees, meets the following standards: * * * * *

(2) * * *

(i) Standards. A QHP issuer in a Federally-facilitated Exchange in a State that CMS has not determined to have an Effective Provider Access Review Program as described in Sec. 155.1050(d) must comply with the requirement in paragraph (a)(1)(ii) of this section by: * * * * *

(ii) Justification. If a plan applying for QHP certification to be offered through a Federally-facilitated Exchange in a State that CMS has not determined to have an Effective Provider Access Review Program as described in Sec. 155.1050(d) does not satisfy the network adequacy standards described in paragraphs (a)(2)(i)(A) and (B) of this section, the issuer must include as part of its QHP application a justification describing how the plan's provider network provides an adequate level of service for enrollees and how the plan's provider network will be strengthened and brought closer to compliance with the network adequacy standards prior to the start of the plan year. The issuer must provide information as requested by the FFE to support this justification.

(3) When CMS is conducting provider access reviews under paragraph (a)(2)(i)(A) and (B) of this section, the Federally-facilitated Exchange may grant an exception to the requirements in paragraphs (a)(2)(i)(A) and (B) of this section if the Exchange determines that

making such health plan available through such Exchange is in the interests of qualified individuals in the State or States in which such Exchange operates.

(4) A limited exception to the requirement described under paragraph (a)(1) of this section is available to stand-alone dental plans issuers that sell plans in areas where it is prohibitively difficult for the issuer to establish a network of dental providers; this exception is not available to medical QHP issuers. Under this exception, an area is considered “prohibitively difficult” for the stand-alone dental plan issuer to establish a network of dental providers based on attestations from State departments of insurance in States with at least 80 percent of counties classified as Counties with Extreme Access Considerations (CEAC) that at least one of the following factors exists in the area of concern: a significant shortage of dental providers, a significant number of dental providers unwilling to contract with Exchange issuers, or significant geographic limitations impacting consumer access to dental providers. * * * * *

0 30. Section 156.235 is amended by revising the section heading, and paragraphs (a)(1), (a)(2) introductory text, (a)(2)(i), (a)(2)(ii) introductory text, (a)(3) and (5), and (b) to read as follows:

Sec. 156.235 Essential community provider standards for network plans.

(a) * * *

(1) A QHP issuer that uses a provider network consisting of in- network providers must ensure that the provider network of each of its QHPs includes a sufficient number and geographic distribution of essential community providers (ECPs), where available, to ensure reasonable and timely access to a broad range of such providers for low-income individuals or individuals residing in Health Professional Shortage Areas within the QHP's service area, in accordance with the Exchange's network adequacy standards.

(2) A network plan applying for QHP certification to be offered through a Federally-facilitated Exchange has a sufficient number and geographic distribution of ECPs if it demonstrates in its QHP application that--

(i) The QHP issuer's provider network includes as participating providers at least a minimum percentage, as specified by HHS, of available ECPs in each network plan's service area collectively across all ECP categories defined under paragraph (a)(2)(ii)(B) of this section, and at least a minimum percentage of available ECPs in each network plan's service area within certain individual ECP categories, as specified by HHS. Multiple providers at a single location will count as a single ECP toward both the available ECPs in the network plan's service area and the issuer's satisfaction of the ECP participation standard. For network plans that use tiered networks, to count toward the issuer's satisfaction of the ECP standards, providers must be contracted within the network tier that results in the lowest cost- sharing obligation. For network plans with two network tiers (for example, participating providers and preferred providers), such as many preferred provider organizations (PPOs), where cost-sharing is lower for preferred providers, only preferred providers will be counted towards ECP standards; and

(ii) The issuer of the network plan offers contracts to-- * * * * *

(3) A network plan applying for QHP certification to be offered through a Federally-facilitated Exchange must include as part of its QHP application the status of contract offers to qualified ECPs available in the network plan's service area. A network plan does not need to report on the status of contract offers for all available ECPs in the network plan's service area, but must at least report on the status of contract offers for all ECPs which the issuer has either included in its network plan or offered a contract to be included in its network plan within each service area. * * * * *

(5) A network plan that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may instead comply with the alternate standard described in paragraph (b) of this section.

(b) Alternate ECP standard. (1) A network plan described in paragraph (a)(5) of this section must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities, to ensure reasonable and timely access for low-income individuals or individuals residing in Health Professional Shortage Areas within the network plan's service area, in accordance with the Exchange's network adequacy standards.

(2) A network plan described in paragraph (a)(5) of this section applying for QHP certification to be offered through a Federally- facilitated Exchange has a sufficient number and geographic distribution of employed or contracted providers if it demonstrates in its QHP application that--

(i) The number of its providers that are located in Health Professional Shortage Areas or five-digit zip codes in which 30 percent or more of the population falls below 200 percent of the Federal poverty level satisfies a minimum percentage, specified by HHS, of available ECPs in each network plan's service area collectively across all ECP categories defined under paragraph (a)(2)(ii)(B) of this section, and at least a minimum percentage of available ECPs in each network plan's service area within certain individual ECP categories, as specified by HHS. Multiple providers at a single location will count as a single ECP toward both the available ECPs in the network plan's service area and the issuer's satisfaction of the ECP participation standard. For network plans that use tiered networks, to count toward the issuer's satisfaction of the ECP standards, providers must be contracted within the network tier that results in the lowest cost- sharing obligation. For network plans with two network tiers (for example, participating providers and preferred providers), such as many PPOs, where cost sharing is lower for preferred providers, only preferred providers would be counted towards ECP standards; and

(ii) The issuer's integrated delivery system provides all of the categories of services provided by entities in each of the ECP categories in each county in the network plan's service area as outlined in the general ECP standard, or otherwise offers a contract to at least one ECP outside of the issuer's integrated delivery system per ECP category in each county in the network plan's service area that can provide those services to low-income, medically underserved individuals.

(3) A network plan applying for QHP certification to be offered through a Federally-facilitated Exchange must include as part of its QHP application the status of contract offers to qualified ECPs available in the network plan's service area. A network plan does not need to report on the status of contract offers for all available ECPs in the network plan's service area, but must at least report on the status of contract offers for all ECPs which the issuer has either included in its network plan or offered a contract to be included in its network plan within each service area. * * * * *

0 31. Add Sec. 156.236 to subpart C to read as follows:

Sec. 156.236 Provider access and essential community providers standards for non-network plans.

(a) A QHP that does not use a network of providers (a non-network plan) must ensure access to a range of providers that accept the non- network plan's benefit amount as payment in full, including essential community providers (ECPs) and providers that specialize in mental health and substance use disorder services, to ensure that services will be accessible without unreasonable delay. A non-network plan does not provide access to a range of providers in this manner by simply providing some benefit amount for covered services rendered by any provider without providing the Exchange any other contextual information.

(b) For plan years beginning on or after January 1, 2028, a non- network plan applying for QHP certification to be offered as a QHP through a Federally-facilitated Exchange must submit the following information to the Federally-facilitated Exchange for a determination that it provides access to a sufficient choice of providers that accept the non-network plan's benefit amount as payment in full, and reasonable and timely access to ECPs that accept the plan's benefit amount as payment in full:

(1) The non-network plan's assessed percentage of providers in each plan's service area that accepts the plan's benefit amount as payment in full; and for ECPs, whether the non-network plan meets at least a minimum percentage, as specified by HHS, of available ECPs that accept the plan's benefit amount as payment in full in each plan's service area collectively across all ECP categories defined under Sec. 156.235(a)(2)(ii)(B), and at least a minimum percentage of available ECPs that accept the plan's benefit amount as payment in full in each plan's service area within certain individual ECP categories, as specified by HHS;

(2) For ECPs, whether the non-network plan offers the benefit amount as payment in full to at least one ECP in each of the eight (8) ECP categories per county in the plan's service area described in Sec. 156.235(a)(2)(ii)(B);

(3) For ECPs, whether the non-network plan offers the benefit amount as payment in full to all available Indian health care providers in the plan's service area;

(4) The non-network plan's strategy for conducting continuous outreach to available providers (including ECPs) in a particular area to determine whether they would accept the plan's benefit amount as payment in full;

(5) The non-network plan's strategy for making benefit amounts publicly available, including to plan enrollees, potential enrollees, and providers (including ECPs), in an easily accessible and understandable format, and for regularly updating any changes to benefit amounts;

(6) The non-network plan's methodology for determining benefit amounts;

(7) The non-network plan's strategy for providing consumer-friendly and public information about potential balance billing scenarios and expected out-of-pocket costs, including historical data on actual out- of-pocket costs incurred by its enrollees while accessing providers (including ECPs) in the area, and information on navigating episodes of care with multiple benefit amounts (including for ancillary providers and services);

(8) The availability of an exceptions process under the non-network plan for enrollees who cannot find providers (including ECPs) willing to accept the benefit amount as payment in full; and

(9) The non-network plan's strategy for providing adequate customer service or online provider directory assistance resources to assist plan enrollees and potential enrollees in finding providers (including ECPs) in their area who will accept the plan's benefit amount as payment in full, and to assist plan enrollees in receiving real-time cost estimates prior to care being furnished.

Sec. 156.265 [Amended]

0 32. Section 156.265 is amended by removing paragraph (b)(3)(iv).

0 33. Section 156.275 is amended by revising paragraphs (a)(1)(viii) and (c)(2)(iv) to read as follows:

Sec. 156.275 Accreditation of QHP issuers.

(a) * * *

(1) * * *

(viii) Provider access; and * * * * *

(c) * * *

(2) * * *

(iv) Provider access. The provider access standards for accreditation used by the recognized accrediting entities must, at a minimum, be consistent with the general requirements for network plans codified in Sec. 156.230(a)(2) and (3) and the general requirements for non-network plans codified in Sec. 156.236(a). * * * * *

0 34. Section 156.480 is amended by revising paragraph (c) introductory text and paragraph (c)(6) to read as follows:

Sec. 156.480 Oversight of the administration of the advance payments of the premium tax credit, cost-sharing reductions, and user fee programs.

* * * * *

(c) Audits and compliance reviews. HHS or its designee may audit or conduct a compliance review of an issuer offering a QHP through an Exchange to assess its compliance with the applicable requirements related to administration of the advance payments of the premium tax credit, cost-sharing reductions, and user fee programs. Compliance reviews conducted under this section will follow the standards set forth in Sec. 156.715. * * * * *

(6) Circumstances requiring HHS enforcement. If HHS determines that the State Exchange or State-based Exchange on the Federal platform is not enforcing or fails to substantially enforce compliance with the applicable requirements related to administration of the advance payments of the premium tax credit, cost-sharing reductions, and user fee programs, then HHS may do so and may pursue the imposition of civil money penalties as specified in Sec. 156.805 for noncompliance by QHP issuers participating in the State Exchange or State-based Exchange on the Federal platform.

0 35. Section 156.800 is amended by revising paragraph (b) to read as follows:

Sec. 156.800 Available remedies; Scope.

* * * * *

(b) Scope. Sanctions under subpart I are applicable for noncompliance with QHP issuer participation standards and other standards applicable to issuers offering QHPs in a Federally- facilitated Exchange. Sanctions under paragraph (a)(1) of this section are also applicable for noncompliance by QHP issuers participating in State Exchanges and State-based Exchanges on the Federal platform when HHS is responsible for enforcement of any of the requirements applicable to the actions identified in Sec. 156.805(a) that are applicable to issuers offering a QHP in a State Exchange or State-based Exchange on the Federal platform. * * * * *

0 36. Section 156.805 is amended by revising paragraphs (b) introductory text and (f) to read as follows:

Sec. 156.805 Bases and process for imposing civil money penalties in Federally-facilitated Exchanges.

* * * * *

(b) Factors in determining the amount of civil money penalties assessed. In determining the amount of civil money

penalties, HHS will identify the lawful purpose or purposes of the civil money penalty, and take into account the following factors as appropriate to the circumstances of the case: * * * * *

(f) Circumstances requiring HHS enforcement in State Exchanges and State-based Exchanges on the Federal platform. (1) HHS will enforce the requirements applicable to the actions identified in paragraph (a) of this section that are applicable to issuers offering a QHP in a State Exchange or State-based Exchange on the Federal platform, if the State with enforcement authority over such Exchange notifies HHS that it is not enforcing these requirements or if HHS makes a determination using the process set forth at 45 CFR 150.201, et seq. that such State is failing to substantially enforce these requirements.

(2) If HHS is responsible under paragraph (f)(1) of this section for enforcement of the requirements applicable to the actions identified in paragraph (a) of this section that are applicable to issuers offering a QHP in a State Exchange or State-based Exchange on the Federal platform, HHS may impose civil money penalties on an issuer in such Exchange, in accordance with the bases and process for imposing civil money penalties set forth in this section.

0 37. Section 156.810 is amended by revising paragraph (a)(8) to read as follows:

Sec. 156.810 Bases and process for decertification of a QHP offered by an issuer through a Federally-facilitated Exchange.

(a) * * *

(8) The QHP issuer substantially fails to meet the requirements under Sec. 156.230 related to provider access standards for network plans, Sec. 156.235 related to essential community provider access standards for network plans, or Sec. 156.236 related to provider access and essential community providers standards for non-network plans, as applicable; * * * * *

0 38. Section 156.903 is amended by adding paragraph (d) to read as follows:

Sec. 156.903 Scope of Administrative Law Judge's (ALJ) authority.

* * * * *

(d) The ALJ, upon his or her own motion or at the request of a party, may issue subpoenas if they are reasonably necessary for the full presentation of a case.

(1) The party must file a written request for a subpoena with the ALJ at least 5 calendar days before the date set for the hearing.

(2) The request must:

(i) Identify the witnesses or documents to be produced;

(ii) Describe their addresses or location with sufficient particularity to permit them to be found; and

(iii) Specify the pertinent facts the party expects to establish by the witnesses or documents, and indicate why those facts could not be established without use of a subpoena.

(3) Subpoenas are issued in the name of the Secretary.

0 39. Section 156.935 is amended by adding paragraph (f) to read as follows:

Sec. 156.935 Discovery.

* * * * *

(f) This section does not apply to appeals of civil money penalties imposed under Sec. 156.805 for violations identified during audits or compliance reviews conducted in accordance with Sec. 156.480(c).

0 40. Section 156.1215 is amended by revising paragraphs (b) and (c) to read as follows:

Sec. 156.1215 Payment and collections processes.

* * * * *

(b) Netting of payments and charges for later years. As part of its payment and collections process, HHS may net payments owed to issuers and their affiliates operating under the same tax identification number against amounts due to the Federal Government from the issuers and their affiliates under the same taxpayer identification number for advance payments of the premium tax credit, advance payments of and reconciliation of cost-sharing reductions, payment of Federally facilitated Exchange user fees, payment of State Exchanges utilizing the Federal platform user fees, HHS risk adjustment, reinsurance, and risk corridors payments and charges, administrative fees for utilizing the Federal Independent Dispute Resolution process in accordance with Sec. 149.510(d)(2) of this subchapter, and civil money penalties assessed for violations of any applicable Exchange standards and requirements or Public Health Service Act standards and requirements applicable to issuers.

(c) Determination of debt. Any amount owed to the Federal Government by an issuer and its affiliates for advance payments of the premium tax credit, advance payments of and reconciliation of cost- sharing reductions, Federally-facilitated Exchange user fees, including any fees for State-based Exchanges utilizing the Federal platform, HHS risk adjustment, reinsurance, risk corridors, unpaid administrative fees for utilizing the Federal Independent Dispute Resolution process in accordance with Sec. 149.510(d)(2), and civil money penalties assessed for violations of any applicable Exchange standards and requirements or Public Health Service Act standards and requirements applicable to issuers, after HHS nets amounts owed by the Federal Government under these programs, is a determination of a debt.

0 41. Section 156.1220 is amended by revising paragraph (b)(1) to read as follows:

Sec. 156.1220 Administrative appeals.

* * * * *

(b) * * *

(1) Manner and timing for request. A request for an informal hearing must be made in writing and filed with HHS within 30 calendar days of the date of the reconsideration decision under paragraph (a)(6) of this section. If the last day of this period is not a business day, the request for an informal hearing must be made in writing and filed by the next applicable business day. * * * * *

Robert F. Kennedy, Jr., Secretary, Department of Health and Human Services. [FR Doc. 2026-10050 Filed 5-18-26; 4:15 pm] BILLING CODE 4120-01-P