CMS audits of qualified health plans to focus on broker standards

The Centers for Medicare and Medicaid say close attention will be paid to compliance with agent/broker standards during audits of qualified health plans offered in the federally facilitated marketplaces in 2015.

Audits of 23 QHPs in 2014 found some plans failed to ensure compliance with agent/broker training and registration requirements, and failed to ensure that agent/broker compensation is equal inside and outside the FFM.

CMS will again in 2015 audit plans for compliance with broker training and registration requirements, as well as ensuring brokers maintain licensure and good standing in each state the agent operates, according to the agency’s list of key priorities for FFM compliance reviews for the 2015 benefit year.

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CMS says it will also audit for compliance with the execution of the FFM Privacy / Security Agreement and (if applicable) the General Marketplace Agreement. In addition, the agency will audit to ensure the required disclaimers are being issued if an agent/broker uses a non-FFM website to assist with QHP selection.

CMS will continue its good faith compliance policy through 2015 for QHP issuers that demonstrate a good faith effort to comply with QHP certification and operational requirements, but the agency has not yet indicated whether it will extend its good faith compliance policy for 2016.

“Issuers should not expect this policy to continue indefinitely and should be prepared for a CMS QHP compliance review,” say legal experts Helaine Fingold and Brian Hall of Epstein Becker Green.

In 2014 audits, the agency found a lack of familiarity with QHP requirements, they say in a client alert, adding that “many of the examined policies and procedures were non-existent, had been recently created prior to the audit date, or did not address QHP-specific requirements.”

If a QHP issuer “fails to implement policies and procedures that reflect FFM requirements, then it will be difficult for the issuer to demonstrate that it has acted in good faith,” they caution.

A new key priority for 2015 audits is prescription drug formulary compliance, including meeting drug coverage minimums and the provision of a process to allow enrollees to request and access clinically appropriate drugs not included in the formulary.

The full list of CMS Key Priorities for FFM Compliance Reviews for the 2015 Benefit Year can be found here. The agency notes the list is not intended to be all inclusive and “as additional final regulations and operational guidance are published, those standards may be included as part of the compliance reviews.”