Federal Register: July 30, 2010 (Volume 75, Number 146)
DOCID: fr30jy10-17 FR Doc 2010-18691
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Workers Compensation Programs Office
CFR Citation: 45 CFR Part 152
RIN ID: RIN 0991-AB71
OCI ID: [OCIIO-9995-IFC]
NOTICE: Part II
DOCUMENT ACTION: Interim final rule with comment period.
Pre-Existing Condition Insurance Plan Program
DATES: Effective date: This regulation is effective on July 30, 2010.
Comment date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on September 28, 2010.
Section 1101 of Title I of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act) requires that the Secretary establish, either directly or through contracts with States or nonprofit private entities, a temporary high risk health insurance pool program to provide affordable health insurance coverage to uninsured individuals with preexisting conditions. This program will continue until January 1, 2014, when Exchanges established under sections 1311 and 1321 of the Affordable Care Act will be available for individuals to obtain health insurance coverage. This interim final rule implements requirements in section 1101 of the Affordable Care Act. Key issues addressed in this interim final rule include administration of the program, eligibility and enrollment, benefits, premiums, funding, and appeals and oversight rules.
Health and Human Services Department
Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://regulations.gov. Follow the search instructions on that Web site to view public comments.
Comments received timely will be also available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments, phone 18007433951.
Historically, public policy has addressed the challenges of people with preexisting conditions through either high risk pools or insurance reform. In general, high risk pools provide coverage of last resort for people who, because of their health, are denied coverage by private insurers or are unable to purchase coverage in the individual market except at substantially surcharged premiums due to their health status, and are ineligible for public coverage (such as Medicare or Medicaid). Most States that permit insurers to decline coverage for health reasons have established high risk pools as an alternative coverage option in their individual market. These current pools provide safety net coverage for people who have difficulty obtaining individual health insurance because of their preexisting conditions. First established in 1976, 35 State high risk pools currently provide coverage to approximately 200,000 individuals, or about one percent of the individual market nationwide, and vary in terms of the populations they cover and the benefits they provide.
States and the Congress through the Affordable Care Act have also
elected to use insurance reforms to address the accessibility and
availability of health insurance coverage for high risk populations.
Seven States have adopted guaranteed issue to ensure access to
coverage, and two States prohibit health status from being a factor in
setting premiums.\1\ The Patient Protection and Affordable Care Act of
2010, (the Affordable Care Act or ``the Act''), Public Law 111148
applies a ban on preexisting condition exclusions and ``rateups'' based on health status starting in
2014 and prohibits the use of preexisting condition exclusions for children starting in plan or policy years that begin on or after September 23, 2010.\2\ This temporary Federal program provides coverage to uninsured Americans with preexisting conditions until the Affordable Care Act is fully implemented in 2014.
\1\ Kaiser Family Foundation. State Health Facts. http:// www.statehealthfacts.org/.
\2\ These provisions do not apply to ``grandfathered'' plans. For a description of these provisions, see the interim final regulations implementing 2719A (regarding patient protections), published in the Federal Register on June 28, 2010 (75 FR 37188). B. Overview: Section 1101 of the Patient Protection and Affordable Care Act
The Affordable Care Act, was enacted on March 23, 2010. The Health Care and Education Reconciliation Act (the Reconciliation Act), Public Law 111152, was enacted on March 30, 2010. Section 1101 of the Affordable Care Act requires that the Secretary of the Department of Health and Human Services (HHS) establish, either directly or through contracts with States or nonprofit private entities, a temporary high risk health insurance program to provide access to coverage for uninsured Americans with preexisting conditions. (Hereafter, we generally refer to this program as the PreExisting Condition Insurance Plan program, or PCIP program, to avoid confusion with the existing State high risk pool programs, which will continue to operate separately.)
The PCIP program is intended to remain in place from the time of
its establishment until the Exchanges established under sections 1311
or 1321 of the Act go into effect on January 1, 2014. This interim
final regulation sets policy only for this unique, temporary Federal
program with fixed Federal funding. Presented below is a general
overview of the statutory requirements for the new program. More
detailed descriptions of the specific requirements are included below
as part of the discussion of the associated regulatory provisions set forth in this interim final rule.
II. Provisions of the Interim Final Rule
A. General Provisions (Subpart A, Sec. 152.1 Through Sec. 152.2)
Section 152.1 of this interim final rule specifies the general statutory authority for the ensuing regulations and the scope of the program, consistent with section 1101 of the Act. Section 152.2 provides definitions for terms that appear throughout these regulations. Generally, the definitions are selfexplanatory or taken directly from section 1101 of the statute. The definitions set forth in subpart A apply to all of part 152 unless otherwise indicated and are applicable only for purposes of part 152.
The definition of ``preexisting condition exclusion'' warrants a brief discussion. First, it is important to note that this definition applies only for purposes of the prohibition in section 1101(c)(2)(A) on a PCIP ``impos[ing] any preexisting condition exclusion'' under the coverage provided (an important protection for a program designed to offer coverage to those with a preexisting condition), and is separate from the ``guidelines'' that determine preexisting condition status under section 1101(d)(2)(3) for purposes of eligibility for enrollment in a PCIP. These latter eligibility provisions are set forth in subpart C of this rule, under section 152.14.
State laws vary with regard to the definition of a preexisting
condition exclusion. For purposes of defining a preexisting condition
exclusion, we adopted the definition of preexisting condition
currently used in the group market under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). We also took into
account section 1201 of the Affordable Care Act, which prohibits
denials of coverage because of a preexisting condition. Thus, we
specify that preexisting condition exclusion has the same meaning as
under 45 CFR 144.103. That is, the term refers to a denial of coverage,
or limitation or exclusion of benefits, based on the fact that the
individual denied coverage or benefits had a health condition that was
present before the date of enrollment for the coverage (or a denial of
enrollment), whether or not any medical advice, diagnosis, care, or
treatment was recommended or received before that date. This would
include exclusions stemming from a condition identified via a pre
enrollment questionnaire or physical examination, or the review of medical records during the preenrollment period.
B. PCIP Program Administration (Subpart B, Sec. 152.6 and Sec. 152.7)
As noted above, section 1101(b) of the Affordable Care Act provides that HHS may ``carry out'' the temporary high risk health insurance pool program either directly or through contracts with eligible entities, which are States and nonprofit entities. Eligible entities must submit a proposal to carry out a PCIP in a time and manner, and containing such information, that the Secretary requires. Section 152.6 establishes the general rules for administration through either a State or by HHS through a nonprofit private entity. Section 152.7 then describes the proposal process and specifies that in order to contract with HHS, the eligible entity's proposal must demonstrate capability to perform all functions necessary for the design and operation of a PCIP, and that its proposed PCIP is in full compliance with all of the requirements of this part.
These standards establish minimum requirements for PCIPs, and are
supplemented by other requirements detailed in solicitation documents
(such as the descriptions of the outreach plan and consumer information
resources that each PCIP will establish) and incorporated into the final contracts with HHS.
B. Eligibility and Enrollment (Subpart C, Sec. 152.14 Through Sec. 152.15)
Section 1101(d) of the Affordable Care Act provides the basic eligibility criteria for the PCIP program, which are set forth under Sec. 152.14. In addition, consistent with the Secretary's general authority under section 1101(c)(2)(D) of the Act to establish requirements for a PCIP, we set forth enrollment and disenrollment requirements in Sec. 152.15.
Eligibility for the PCIP Program (Sec. 152.14)
Under section 1101(d) of the Affordable Care Act and subparagraphs
(1), (2) and (3) of Sec. 152.14(a) of this interim final rule, an
individual is eligible to enroll in a PCIP if he or she: (1) Is a
citizen or national of the United States or is lawfully present in the
United States as determined in accordance with section 1411 of the
Affordable Care Act; (2) has not been covered under creditable
coverage, as defined in section 2701(c)(1) of the Public Health Service
Act as of the date of enactment, during the 6month period prior to the
date on which he or she is applying for coverage through the PCIP; and
(3) has a preexisting condition, as determined in a manner consistent
with guidance issued by the Secretary. We further provide in Sec.
152.14(a)(4) that an individual must be a resident of a State that falls within the service area of a PCIP.
Eligibility Conditioned on Citizenship and Immigration Status
Eligibility for the PCIP program is limited to citizens or
nationals of the United States and individuals who are lawfully present
in the United States. For the purpose of this regulation, lawfully
present has the meaning presently used under the Children's Health
Insurance Program, provided in the State Health Official letter issued by
the Centers for Medicare and Medicaid Services (CMS) on July 1, 2010. Section 1101(d)(1) directs the Secretary to make a determination of citizenship and immigration status in accordance with section 1411 of the Act, which describes procedures to be employed for determining eligibility for the Exchanges and provides for these procedures also to be used in determining eligibility for the PCIP program. This section sets forth detailed requirements governing the type of information that applicants must provide and specific verification procedures that the Secretary of Health and Human Services, Commissioner of Social Security, and Secretary of Homeland Security would be required to follow to establish eligibility. Section 1411(c)(4) of the Affordable Care Act further provides that the Secretary shall conduct verifications and determinations ``through the use of an online system or otherwise for the electronic submission of, and response to, the information submitted * * * with respect to an applicant,'' or by ``such other method as is approved by the Secretary'' that determines ``the consistency of the information submitted with the information maintained in the records of the Secretary of the Treasury, the Secretary of Homeland Security, and the Commissioner of Social Security''.
Under this authority, Sec. 152.15(a)(3) specifies that a PCIP must verify that an individual is a United States citizen or national, or lawfully present in the United States. A PCIP can verify an individual's citizenship or immigration status through the Social Security Administration or, if applicable, the Department of Homeland Security. In many cases, States may be able to automate verification of citizenship and immigration status by leveraging existing data exchanges that are currently in place for other programs, such as Medicaid and the Children's Health Insurance Program. The Department of Homeland Security's U.S. Citizenship and Immigration Services (USCIS) Systematic Alien Verification for Entitlements (SAVE) program provides online system to verify an individual's immigration status. States can access this system after entering into the necessary Memorandum of Understanding with USCIS. An automated verification process will be used in all States where HHS is administering the PCIP program.
Some States are not able to have an automated ``online system'' or
``electronic'' process in place when they start accepting enrollments
into their PCIPs. Therefore, these regulations provide, as an
``alternative method'' approved by the Secretary, that a PCIP program
may instead require the individual to provide documentation that
establishes citizenship or immigration status. Subject to HHS approval,
States using documentation procedures may switch to an automated system
in the future. If a PCIP shares such information with the Social
Security Administration or the Department of Homeland Security,
consistent with the Privacy Act, the regulation specifies that a PCIP
must include a disclosure that the information provided on the
enrollment request may be shared with other government agencies for
purposes of establishing eligibility. The type(s) of documentation
PCIPs may use is subject to approval by HHS under the terms of the contract.
Eligibility Based on a 6Month Period Without Insurance Coverage
Eligibility for the PCIP program is limited to individuals with no creditable coverage during the 6month period prior to the date on which they apply for coverage through the PCIP. Section 2701(c)(1) of the Public Health Service Act on the date of enactment and 45 CFR Sec. 146.113(a)(1) define creditable coverage as coverage of an individual under a group health plan, health insurance coverage as defined at 45 CFR 144.103, Medicare Part A or Part B, Medicaid, the Children's Health Insurance Program, the TRICARE program, a medical care program of the Indian Health Service or of a tribal organization, a State health benefits risk pool (that is, existing State high risk pool), the Federal Employee Health Benefits program, a public health plan (for example, coverage through the Veterans Administration), or a health benefit plan offered under section 5(e) of the Peace Corps Act. Such creditable coverage includes health coverage provided to certain former employees, retirees, spouses, former spouses, and dependent children who are entitled to temporary continuation of health coverage at group rates under the Consolidated Omnibus Reconciliation Act of 1985 (COBRA). We specify under Sec. 152.14(b)(3) that if an individual has already satisfied the requirement for a 6month period without creditable coverage in connection with qualifying for a given PCIP under section 1101 of the Act, the individual will be considered to have satisfied this eligibility requirement for purposes of a PCIP in another State, if such individual moves to a different State and wishes to enroll in that State's PCIP.
In light of the unique circumstances presented by infants who are less than six months old, the Department will issue guidance on how the requirement that the individual not have had creditable coverage during the sixmonth period prior to the application for the PCIP program applies to and can be satisfied by such infants. Factors to be considered in this guidance include whether coverage in the hospital under the mother's plan at birth counts, current practices regarding insurers' coverage of newborns, and the antidumping rules that direct the Secretary to prevent disenrollment of individuals from existing insurance due to their health status.
Eligibility Based on Having a PreExisting Condition
Under section 1101(d)(3), eligibility for the PCIP program is conditioned on individuals having a preexisting condition, as ``determined in a manner consistent with guidance issued by the Secretary.'' We specify at Sec. 152.14(c)(1) that a PCIP in a State, or the PCIP run by a nonprofit in States that are not carrying out the PCIP program, may determine that an individual has a preexisting condition, for purposes of PCIP eligibility, based on satisfying any one or more of the following criteria, subject to HHS approval: (1) The individual provides documented evidence that an insurer has refused, or has provided clear indication that it would refuse, to issue individual coverage on grounds related to the individual's health; (2) the individual provides documented evidence that he or she has been offered individual coverage but only with a rider that excludes coverage of benefits associated with a preexisting condition; (3) the individual provides documented evidence that he or she has a medical or health condition specified by the State and approved by the Secretary; or (4) other criteria as defined by the PCIP and approved by HHS.
We believe that these criteria are fully consistent with the intent
of section 1101(d)(3) of the Act and address the problems that
individuals with preexisting conditions face when applying for
insurance coverage in the individual market. That is, individuals with
preexisting conditions are often unable to obtain coverage for reasons
that include an outright denial and an exclusion of coverage for the
preexisting condition. This includes instances when an individual
applies for coverage and is informed by the carrier's representative or
Web site that they would be denied for coverage by the carrier due to
the preexisting condition. Providing States and nonprofit entities operating a PCIP
the option of using these manifestations of having a preexisting condition, rather than relying on a list of medical conditions, is consistent with the PCIP program goal of covering people who both have a preexisting condition and otherwise cannot access insurance. We note that in some cases, individuals with preexisting conditions are unable to obtain outright written coverage denials, but instead are told that carriers will not accept their applications. These regulations will permit PCIPs to exercise flexibility in determining exactly what type of communication constitutes a refusal to issue coverage.
Under Sec. 152.14(c)(3), we specify that a PCIP may determine that an individual has a preexisting condition based on evidence of the existence or history of certain medical or health conditions, as approved by the Secretary. This provision comports with our intention to permit the continuing use of eligibility standards that States use in their existing high risk pools, and permits a State that has guaranteed issue and community rated premiums to use an alternative test to showing a denial of coverage.
Finally, we provide at Sec. 152.14(c)(4) that HHS may approve other criteria for meeting the definition of preexisting condition under a given PCIP.
We anticipate that the first two criteria will be used in all
States where individuals may be denied coverage or offered coverage
with exclusionary riders. In the PCIP program serving States that have
elected not to play a role in operating a PCIP program, only the first
two criteria will be used, except with respect to individuals who are
guaranteed to be issued a policy. PCIPs administered by States or non
profit entities may choose to utilize the additional criteria with HHS approval.
Eligibility for a PCIP Conditioned on Residing in the Plan's Service Area
Eligibility for a PCIP is limited to individuals who reside in the service area of the PCIP. At Sec. 152.14(a)(4), we provide that an individual must be a resident of one of the 50 States or the District of Columbia which constitutes or is within the service area of the PCIP.
The statute explicitly acknowledges the role of a State (defined in section 1304(d) of the Act as the 50 States and the District of Columbia) with respect to the administration of PCIP, with no reference to ``Territories'' (see 1101(b)(2) and (3), 1101(e)(3), 1101(g)(3)(A) and (5)). Unlike section 1204(a) of the Health Care and Education Reconciliation Act of 2010, (which amended the Affordable Care Act and clearly specified a role for territories in the operation of Exchanges), the Congress made no similar reference to Territories in connection with the PCIP program.
Enrollment and Disenrollment Process (Sec. 152.15)
Under our authority in section 1101(c)(2)(D) of the Act to impose ``appropriate'' requirements that PCIPs would be required to meet, Sec. 152.15(a) and (b) require PCIPs to establish a process for enrolling and disenrolling individuals that is approved by HHS. Our intent is to permit the use of established enrollment policies and procedures in place under existing State high risk pools, to the extent that they are consistent with the statute.
Section 152.15(a)(2) of this interim final rule specifies that a PCIP must allow an individual to remain enrolled unless the individual is disenrolled under specified circumstances (for example, the individual moves out of the service area or obtains other creditable coverage) or the PCIP program is terminated. Our intent is to promote continuity of coverage for individuals who enroll in a PCIP until they are able to obtain coverage through the Exchange, under which participating insurers cannot exclude individuals with preexisting conditions. We understand, however, that to the extent individuals can obtain other coverage, for example, by becoming entitled to Medicare or enrolling in employerbased health insurance, such coverage would obviate the need for coverage provided by the PCIP. Leveraging the availability of such coverage, by exiting the PCIP, enables other qualified individuals to enroll.
A PCIP is required to establish, consistent with Sec. 152.15(b) of this interim final rule, a disenrollment process that is approved by HHS. As noted above, we seek to support States' ability to participate in this program by allowing them to adopt policies and procedures in use under existing high risk pool programs. We understand that current practice in State high risk pools is that an individual who does not pay his or her premiums on a timely basis may be disenrolled. We provide in Sec. 152.15(b)(2) that, under these circumstances, the enrollee will receive sufficient notice and reasonable grace period for payment prior to any disenrollment taking effect not to exceed 61 days (the longest period currently provided for by States). The consequence of failing to pay premiums and any subsequent disenrollment is that an individual loses access to coverage and may not be able to reenroll for 6 months. Thus, we believe that it is the PCIP's responsibility to inform its enrollees prior to making a disenrollment effective. There are other circumstances in which involuntary disenrollment is appropriate and thus we establish at Sec. 152.15(b)(3) that a PCIP must disenroll an individual in cases of death, where an individual obtains creditable coverage or no longer resides in the PCIP's service area, and other exceptional circumstances as established by HHS. We envision that such circumstances would include cases of fraud or intentional misrepresentation of material fact, and it is our intent to work with PCIPs to develop policies in these areas via subregulatory guidance. As we explain under our discussion of eligibility, an individual who is disenrolled because he or she no longer resides in the service area of a PCIP does not have to satisfy another 6month continuous period without creditable coverage before applying to enroll in a PCIP in the new State of residence.
Section 152.15(c) requires that a PCIP establish rules governing effective dates of enrollments and disenrollments. In particular, a PCIP program must specify the deadline for receiving an enrollment application that would take effect on the first of the following month. In general, an individual who submits a complete enrollment request by an eligible individual by the 15th day of a month could access coverage by the 1st day of the following month. Exceptions to this policy will be subject to approval by HHS.
Finally, given the capped appropriation for this program, we
recognize that PCIPs need sufficient programmatic flexibility to manage
their costs and enrollment, to help ensure that the PCIP program's
funding allocation is sufficient to cover claims and other program
costs for the entire duration of the program. Thus, we establish
authority under Sec. 152.15(d) for a PCIP program to employ strategies
to manage enrollment over the course of the program that may include
enrollment capacity limits, phasedin (delayed) enrollment, premium and
benefit adjustments that indirectly affect enrollment, and other measures, as defined by the PCIP and approved by HHS.
Benefits(Subpart D, Sections 152.19 Through 152.22)
Covered Benefits (Sec. 152.19)
Required Benefits (Sec. 152.19(a))
The required benefit list in Sec. 152.19(a) builds off of the
essential health benefits under the new section 2707 of the Public
Health Service Act, as enacted in the Affordable Care Act, for which [[Page 45018]]
guidance has yet to be issued. The list is consistent with the most commonly covered services offered in existing State high risk pools, according to a survey conducted by the National Association of State Comprehensive Health Insurance Plans (NASCHIP) in 2009. Its benefits are also parallel to the benefits offered by the Federal Employees Health Benefits Plan (FEHBP).
Excluded Services (Sec. 152.19(b))
Section 152.19(b) sets forth a list of services that shall not be covered by any PCIP. While the specific benefits to be included and excluded by any PCIP are generally subject to HHS approval and review through the PCIP contracting process, this excluded services list addresses several areas where providing coverage is unequivocally prohibited. This list of excluded services parallels that of FEHBP.
The subject of Federal funding of abortion services with respect to the Affordable Care Act was addressed in the Executive Order issued by the President on March 24, 2010: The enactment of the Affordable Care Act left in place current restrictions that prohibit the use of Federal funds for abortion services, except in cases of rape or incest, or where the life of the woman would be endangered. Exec. Order No. 13,535, 75 FR 15,599 (Mar. 24, 2010). These restrictions currently apply to certain Federal programs that are similar to the PCIP program. The PCIP program is Federallycreated, funded, and administered (whether directly or through contract); it is a temporary Federal insurance program in which the risk is borne by the Federal government up to a fixed appropriation. As such, the services covered by the PCIP program shall not include abortion services except in the case of rape or incest, or where the life of the woman would be endangered. PreExisting Conditions Exclusions (Sec. 152.20)
Section 1101(c)(2)(A) of the Act requires that a PCIP established under this section not impose any preexisting condition exclusions with respect to covered services. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes limitations for pre existing conditions in the group market. This protection was expanded under section 1201 of the Affordable Care Act, which prohibits any pre existing condition exclusions from being imposed by group health plans or group and individual health insurance coverage beginning January 1, 2014. The interim final rules issued pursuant to section 2704 of the Public Health Service Act (as amended by the Affordable Care Act) under Sec. 147 adopt, with minor modifications, the definition of pre existing condition currently used under HIPAA.
Similarly, our rule prohibits PCIPs from applying any preexisting condition exclusion to covered services, and consistent with the regulations implementing section 1201 of the Act, defines a pre existing condition exclusion as a limitation or exclusion of benefits based on the fact that the condition was present before the date of enrollment in coverage (or a denial of enrollment), whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.
Pursuant to the authority provided to the Secretary under section
1101(c)(2)(D), this interim final rule also prohibits PCIPs from
imposing any type of coverage waiting period upon eligible individuals.
For purposes of this rule, a waiting period is defined as the period
immediately following the effective date of enrollment in which some or
all benefits in the coverage are not provided. Accordingly, once an
individual is enrolled in a PCIP consistent with the rules set forth in
subpart C, full coverage must be provided to the individual starting with the effective date of enrollment.
Premiums and CostSharing (Sec. 152.21)
Section 1101(c)(2)(C)(iii) of the Act requires that premium rates charged for coverage under the high risk pool program be established at ``a standard rate for a standard population''. The National Association of Insurance Commissioners (NAIC) Model Health Plan for Uninsurable Individuals Act suggests that high risk pool plans ``determine a standard risk rate by considering the premium rates charged by other insurers offering health insurance coverage to individuals.'' Furthermore, section 2245(g)(2) of the Public Health Service Act (PHSA), which governs the existing Federal high risk pool grant program, defines the ``standard risk rate'' for the high risk pools to mean a rate that: (1) Is determined under the State high risk pool by considering the premium rates charged by other health insurers offering health insurance coverage to individuals in the insurance market served; (2) is established using reasonable actuarial techniques; and (3) reflects anticipated claims experience and expenses for the coverage involved.
In keeping with the methodology suggested by the NAIC Model Act and the Federal grant program, Sec. 152.21 of this interim final rule generally interprets the phrase ``standard rate for a standard population'' to refer to the premium rates offered in the individual market in a given State. While existing State high risk pools' premiums vary between 105250 percent of the standard rate of the individual market, the Act requires that premiums in the PCIP program be at the standard rate, rather than a higher proportion of that rate. Therefore, this rule provides that a PCIP established under this section must not offer enrollees premiums at a rate that exceeds 100 percent of the standard individual market rate in the PCIP service area.
This interim final rule does not mandate a specific formula for calculating the standard rate. Instead, we specify that a PCIP may calculate the standard rate using reasonable actuarial techniques, as approved by the Secretary, that reflect anticipated experience and expenses. This requirement should accommodate reasonable variations in the methods that PCIPs may use to calculate a standard risk rate.
We also recognize that individual market rates in each State can vary as a consequence of individual State insurance laws. For example, some States require that insurers issue all applicants a policy or offer coverage at a community rate. In such situations, the standard individual rate may be considerably higher than in a State that permits insurers to reject applicants or set premiums on the basis of health status or other factors. To account for these variations, Sec. 152.21(a) of these rules provides that, subject to approval by HHS, a PCIP may use other methods of determining the standard rate in the State. The exact methodology must be submitted and approved through the proposal process as specified in Sec. 152.8 of this part.
Section 1101(c)(2)(C)(ii) of the Act specifies that premium rates
in a PCIP can vary on the basis of age by a factor not greater than 4
to 1. Section 2701(a)(3) of the PHSA as amended by the Affordable Care
Act requires HHS, in consultation with NAIC, to define permissible age
bands for rating purposes in the individual and group markets. However,
the rating bands established under section 2701 will not be effective
until January 1, 2014, and no such requirement exists for the PCIP
program. Given these factors, this rule does not establish standard age bands
for the PCIP program beyond the statutory requirements. Thus, Sec. 152.21(a)(2) of this rule simply follows the statutory requirement of section 1101(c)(2)(C)(ii) of the Act and provides that premiums charged in the PCIP can vary by age on a factor of not greater than 4 to 1. Specific age band rating will be established through the PCIP contracting process.
Section 1101(c)(2)(C)(i) of the Act requires that premiums in the PCIP program may vary only as provided under section 2701 of the PHSA, other than what is allowed in section 1101. Section 2701 permits premiums rates to vary in the individual and group markets by a finite number of factors. Gender rating, for example, is prohibited in the PCIP program.
Limits on Enrollee Costs
Section 1101(c)(2)(B) of the Act sets limits on enrollee costs in the PCIP program. Specifically, the issuer's share of the total allowed costs of benefits provided under such coverage cannot be less than 65 percent of such costs, subject to actuarial review and approval by the Secretary. Section 152.21(b)(1) of this rule provides that coverage under a plan offered by a PCIP must at a minimum meet this 65 percent threshold.
Section 1101(c)(2)(B)(ii) of the Act requires that coverage provided by PCIPs not have an outofpocket limit greater than the applicable amount described in section 223(c)(2) of the Internal Revenue Code, which sets the outofpocket limit for high deductible health plans associated with a tax favored health savings accounts. (This amount is $5,950 for 2010.) Under Sec. 152.2, we define outof pocket costs as the sum of the annual deductible and the other annual outofpocket expenses, other than for premiums, required to be paid under the plan. Section 152.21(b)(2) also notes that, consistent with IRS rules, the outofpocket limit may be applied only for innetwork providers, consistent with the terms of PCIP plan benefit package. Access to Services (Sec. 152.22)
As noted above, section 1101(c)(2)(D) of the Act provides that coverage offered via a PCIP must meet any other requirements determined appropriate by the Secretary of HHS. Section 152.22 provides that the PCIP may specify the network of providers from whom enrollees may obtain services, provided that the PCIP demonstrates to HHS that it has a sufficient number and range of providers to ensure that all covered services are reasonably available and accessible under such coverage. Section 152.22(b) makes clear that, in the case of emergency room services, such services must be covered out of network and out of area if (1) the enrollee had a reasonable concern that failure to obtain immediate treatment could present a serious risk to his or her life or health; and (2) the services were required to assess whether a condition requiring immediate treatment exists, or to provide such immediate treatment where warranted. We believe these requirements are in keeping with generally accepted standards with respect to the provision of emergency services in plans with network limits, such as those in place in the Medicare Advantage program under title XVIII of the Social Security Act and the commercial health insurance market. E. Oversight (Subpart E, Sections 152.26 Through 152.28)
Appeals Procedures (Sec. 152.26)
Section 1101(f)(1) of the Act requires the establishment of an appeals process to enable individuals to appeal determinations under the PCIP program. We are interpreting this provision to apply both to determinations with respect to benefit coverage determinations and determinations with respect to an individual's eligibility for the program, including whether an individual is a citizen or national of the United States, or lawfully present in the United States.
Rather than establishing detailed, proscriptive requirements with
respect to appeals procedures, Sec. 152.26 of this interim final rule
establishes minimum requirements that all PCIPS must meet. Section 152.26(b) specifies that a PCIP must provide for a timely
redetermination of an eligibility or coverage determination; coverage determinations include both whether an item or service is covered and the amount paid by the PCIP. For coverage determinations, Sec. 152.26(b)(3) further specifies that an enrollee has the right to a timely secondlevel appeal, or ``reconsideration,'' by an independent entity.
The requirement for independent review of a plan's coverage redetermination ensures that the entity providing the reconsideration would have no stake of any kind in the outcome, and was not involved in the initial or reconsidered determination being reviewed. This requirement could be satisfied under a variety of arrangements, including (1) An existing appeal mechanism provided for under State law; (2) in the case of a Stateadministered PCIP, a review process created by the State; or (3) an independent contractor, such as the independent review entities with which HHS contracts to review coverage determinations under the Medicare program.
These requirements are intended to permit States to use existing appeals or review mechanisms provided for under State law, and to permit other nonprofit entities to utilize their existing internal appeals mechanisms. The actual appeals mechanisms will be subject to the Secretary's approval as part of the contracting process. Given both the temporary nature of the program and the statutory implementation timeframe for the new program, we believe that using these existing mechanisms is necessary and appropriate.
Fraud, Waste, and Abuse (Sec. 152.27)
Section 1101(f)(2) of the Affordable Care Act requires the Secretary to establish procedures to protect against fraud, waste, and abuse. To that end, Sec. 152.27(a) of this interim final rule requires the PCIP to develop, implement, and execute operating procedures to prevent, detect, recover payments (when applicable or allowable), and promptly report to HHS incidences of waste, fraud, and abuse. These procedures are required to include identifying situations in which enrollees, potential enrollees, or their family members had access to employerbased coverage, and may have been discouraged from enrolling in that coverage. Should HHS become aware of instances involving fraud, waste, or abuse within the PCIP's operation, HHS will take appropriate action within the terms of the contract, or as otherwise provided by law. As stated in Sec. 152.27(b), the PCIP shall cooperate with Federal law enforcement and oversight authorities in cases involving waste, fraud and abuse, and shall report cases in which an individual may have been discouraged from enrolling in other coverage to appropriate authorities. For example, if the coverage was an employer group health plan subject to ERISA, which prohibits discrimination based on health status, the matter should be reported to the Department of Labor for investigation and possible enforcement action. Preventing Insurer Dumping (Sec. 152.28)
There is an incentive for employers and issuers to single out high
risk and thus highcost individuals and offer incentives for them to
disenroll from their coverage and obtain coverage in PCIPs which offer
such individuals guaranteed access to coverage without preexisting
condition exclusion at a standard premium, if they are uninsured [[Page 45020]]
for at least six months. Congress recognized this potential issue and directed the Secretary under section 1101(e)(2) of the Act to establish criteria for determining whether health insurance issuers and employmentbased health plans have discouraged individuals from remaining enrolled in prior coverage based on the health status of those individuals, and specifies certain criteria that shall be included in those established by the Secretary. Section 152.28 of this interim final rule thus sets forth these criteria, and requires that PCIPs establish procedures to identify and report to HHS instances where health insurance issuers or group health plans are discouraging highrisk individuals from remaining enrolled in their current coverage, in instances where such individuals subsequently are eligible to enroll in the PCIP.
Consistent with section 1101(e)(2) of the Affordable Care Act,
section 152.28(c) of the interim final rule provides that if, in
applying the criteria in section 152.28(b), it is determined that a
dumping under section 152.28(a) has occurred, the Secretary may bill
the issuer or group health plan for any medical expenses incurred by
the PCIP for such enrollees. In these situations, the interim final
rule also makes clear that the issuer or group health plan will be
referred to appropriate Federal and State authorities for other
enforcement action that may be warranted depending on the facts and
circumstances. Finally, section 152.28(d) specifies that nothing in the
subsection may be construed as constituting exclusive remedies for
violations of the section or preventing States from applying or
enforcing this section or other provisions of law with respect to
health insurance issuers, consistent with section 1101(c)(3) of the
Affordable Care Act. Additional guidance will be issued to prevent
``dumping'' from public programs like Medicaid and the Children's Health Insurance Program.
F. Funding (Subpart F, Sections 152.32 Through 152.35)
Use of Funds (Sec. 152.32)
Section 1101(g) of the Affordable Care Act appropriates $5,000,000,000 to pay the claims and administrative costs of the PCIP program established under this section that are in excess of the amount of premiums collected from enrollees. Traditionally, in State high risk pools, as well as other insurance programs, the funds collected from enrollees as premiums and other funding streams are expended across two chief areas. The majority of funds collected as premiums are expended to pay the health expenses for covered services incurred by enrollees. Administrative expenses, the costs of operating the program, make up the second major expense category. Section 152.32(a) of this interim final rule thus provides that all funds awarded under this program must be used exclusively to pay the allowable claims and administrative costs of a PCIP established under this section. Such costs include those incurred in the development and operation of the PCIP program, to the extent that those costs are in excess of the amounts or premiums collected from individuals enrolled in the program. PCIP program funds are not available for any other uses, such as to pay expenses or defray premiums of existing State high risk pools.
Although the Act does not specify the amount that a PCIP can spend on administrative expenses, Sec. 152.32(b) of this rule permits PCIPs to spend no more than 10 percent of its total allotted funds towards administrative expenses. The 10 percent limitation is similar to what is imposed under the Children's Health Insurance Program (CHIP). Typical examples of the types of administrative costs and expenses that we expect to be incurred by PCIPs include: Startup and program implementation activities, the production and distribution of information and outreach materials, eligibility determination and enrollment processing, claims processing, costs associated with prevention and detection of fraud, waste and abuse, and other ancillary services such as operation of a customer service call center, account maintenance, and appeals. We note that, given the startup costs for the new PCIPs established under this program, and the need for expeditious implementation, this 10 percent cap applies to the total allotment for the duration of the program, as opposed to spending in a given year.
Initial Allocation of Funds (Sec. 152.33)
Section 1101(g) of the Act does not specify exactly how HHS should allocate funds for the purpose of this program. At the outset of the program, as specified under section 152.33, the Secretary has established initial allotment ceilings for PCIPs in each State using a methodology consistent with the funding allocation methodology used in CHIP, as set forth under 42 CFR Part 457, subpart F, Payment to States. (Note that, subject to these allocation ceilings, the estimated funding amounts available under the PCIP program contracts are established through the contracting process based on the projected number of PCIP enrollees and their projected claims costs. Actual payments to PCIPs will be based on their reported cost statements during the life of the contract.)
Thus, the initial ceilings on PCIP funding allocations are based on a blended formula based on the State population, number of uninsured individuals under 65, and geographic health care costs. Under this formula, one half of the available funds are allocated based on the number of the nonelderly population in each State, compared to the total U.S. nonelderly population. This gives more populous States more funding and does not penalize those States that employ mechanisms to reduce the number of uninsured persons in their States.
The health care cost index that HHS will use to adjust the funding allocations will be based on the wages of employees in the health services industry, and is consistent with what we have used under the Children's Health Insurance Program. These wage data were developed by the Bureau of Labor Statistics of the Department of Labor through its Quarterly Census of Employment and Wages. This will include a weighted average of the wages in the health services industry represented by ambulatory health care services, hospitals, and nursing and residential care facilities. As in the CHIP formula, 15 percent of the cost factor is held constant, while 85 percent reflects how each State's average wage compares to the U.S. average. In order to insure that the geographic variation and cost adjustments accurately reflect statistics on population and the number of uninsured, the same year of data will be used to calculate population, number of uninsured, geographic health care costs, and cost adjustments.
Reallocation of Funds (Sec. 152.34)
As noted above, over time, spending under the PCIP program will be
determined based on the actual enrollment and cost experience of the
PCIPs across the country. Thus, we recognize that there may be a need
to reallocate funds if actual experience indicates that, in a given
State, not all of funds available under the allocation formula will be
used. Section 152.34 accounts for this possibility by giving HHS
explicit authority to reallocate funds among States if HHS determines
that the PCIP in a given State will not make use of the total estimated
funding originally allotted to that State. HHS will be receiving
monthly reports on the program costs of each PCIP and will consult
closely with PCIPs in evaluating these reports and making any decisions [[Page 45021]]
with respect to the need for reallocations.
Insufficient Funds (Sec. 152.35)
Section 1101(g)(2) of the Affordable Care Act states that if HHS estimates for any fiscal year that the aggregate amounts available for the payment of the expenses of the high risk pool will be less than the actual amount of such expenses, HHS shall make such adjustments as are necessary to eliminate this deficit. Further, section 1101(g)(4) of this Act states that HHS has the authority to stop taking applications for participation in the program to comply with the funding limitations. Accordingly, Sec. 152.35(c) of this rule provides that the PCIP, subject to HHS approval, may adjust premiums, alter required benefits, limit PCIP applications or take other measures to eliminate a projected deficit. Particularly in view of the capped appropriation for the PCIP program, HHS is committed to working very closely with the PCIPs to monitor PCIP enrollment and claims experience. To that end, the PCIP contracts include detailed reporting responsibilities with respect to PCIP enrollment and spending, as well as spelling out PCIP responsibilities for the development of mitigation strategies and recommended adjustments should the amounts available under a contract be less than the projected expenses. Lastly, Sec. 152.35(d) ensures that, if the Secretary estimates that aggregate amounts available for PCIP expenses will be less than the actual amount of expenses, HHS reserves the right to make such adjustments as are necessary to eliminate such deficit, consistent with the terms of the PCIP contract. G. Relationship to Existing Laws and Programs (Subpart G, Sec. 152.39 Through Sec. 152.40)
Relationship to Other Federal Health Insurance Regulation
We note that subtitles A and C of Title I of the Affordable Care Act contain new requirements that apply to group health plans and issuers of health insurance in the individual health insurance market which are governed by title XXVII of the PHSA. Some of these provisions address the same areas as the above provisions in section 1101 governing the PCIP program (e.g., premium amounts, beneficiary outof pocket expenses, and preexisting conditions). These insurance reforms do not apply to the PCIP established under section 1101 of the Affordable Care Act and implemented in this interim final rule since the high risk pools do not meet the definition of a group health plan or a health insurance issuer pursuant to sections 2791(a)(1) and 2791(b)(2) of the PHS Act.
Maintenance of Effort (Sec. 152.39)
Section 1101(b)(3) of the new law imposes a maintenance of effort requirement, which specifies that in order for a State to enter into a contract to administer a PCIP, a State must agree not to reduce the annual amount it expended on the operation of an existing State high risk pool in the year preceding the year in which a PCIP contract begins. We believe that the clear intent of this provision is to prohibit the shifting of costs of existing State high risk pools to the Federal government. The maintenance of effort requirement both ensures that the fixed $5 billion in funding is used to meet the PCIP program goals and also reinforces the limitation of eligibility to individuals who are uninsured, as opposed to those already insured through a State high risk pool. At the same time, we recognize that States now use different sources of funds to support the operation of existing high risk pools. For example, many States rely upon assessments on the health insurance industry or health insurance providers to support their high risk pools, and States also commonly allow insurers to reduce premium tax payments by all or a percentage of such assessment.
Given the various funding models that are now in place in different States, we believe it is appropriate to permit States some latitude in terms of ways in which they can satisfy this requirement subject to Secretarial approval. Accordingly, section 152.39(a) specifies that in order for a State to enter into a contract with the Secretary it must comply with the maintenance of effort requirement set forth in section 1101(b)(3) of the Affordable Care Act in a manner approved by the Secretary. We anticipate that permissible methods of meeting this requirement would include, but are not limited to, maintaining either the total amount or the total per capita amount of State funding for the operation of an existing high risk pool (given that a State would be maintaining its effort per enrollee, and cannot control disenrollment), maintaining the same formula for providing funding for a State high risk pool, or establishing an altered formula that the Secretary determines will not reduce the total funds expended on the existing high risk pool. (Note that options such as the per capita approach would need to be evaluated in terms of other policies in effect in a State that could negatively influence enrollment in an existing State high risk pool.) Again, all such approaches are subject to the approval of the Secretary.
Section 152.39(b) specifies that in situations where a State enters into a contract with HHS under this part, HHS shall take appropriate action, such as terminating the PCIP contract, against any State that fails to maintain funding levels for existing State high risk pools. Relation to State Laws (Sec. 152.40)
Section 152.40 of this interim final rule reflects the provision in
section 1101(g)(5) that specifies State standards that might otherwise
apply to the coverage offered under a PCIP program are preempted, with
the exception of laws relating to licensing or solvency. This language
tracks similar language that applies to State regulation of health
plans offering Medicare Advantage plans under Medicare Part C or drug
coverage under Medicare Part D under title XVIII of the Social Security
Act, and we would expect to interpret the language for purposes of the
PCIP program in a manner similar to the way HHS has applied it under those programs.
H. Transition to Exchanges (Subpart H, Sec. 152.44 Through Sec. 152.45)
End of PCIP Coverage (Sec. 152.44)
Section of 152.44 of this interim final rule specifies that, consistent with section 1101(g)(3)(A) of the Affordable Care Act, enrollee coverage under the PCIP program will end effective January 1, 2014, because affordable coverage will be available under the Exchanges and insurance plans will no longer be permitted to exclude coverage for preexisting conditions. Note that PCIP program contracts will remain in effect to provide for appropriate contractual close out periods, but coverage of claims under the PCIP program will extend only to the costs of covered services provided up through December 31, 2013.
Transition to the Exchanges (Sec. 145.45)
As provided by section 1101(g)(3)(B) of the Affordable Care Act,
HHS will develop procedures to transition PCIP enrollees to the
Exchanges (exchanges) that are established under sections 1311 or 1321
of the Act, in order to ensure there are no lapses in coverage for
individuals enrolled in the PCIP program. Since these exchanges are
still in the developmental stages, we believe it would be premature to
specify transition procedures in this interim final rule. Thus, section
152.45 simply establishes that HHS will develop such transition procedures, and we encourage
comments on the best ways to carry out the transition.
III. Response to Comments
Because of the large number of public comments we normally receive on Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document.
IV. Waiver of Proposed Rulemaking
We ordinarily publish a notice of proposed rulemaking (NPRM) in the Federal Register and invite public comment on the proposed rule before publishing a final rule that responds to comments and sets forth final regulations that generally take effect sixty days later. This procedure can be waived, however, if an agency finds good cause that a notice andcomment procedure is impracticable, unnecessary, or contrary to the public interest and incorporates a statement of the finding and its reasons in the rule issued.
The Affordable Care Act was enacted on March 23, 2010, and requires that a temporary high risk pool program be in place ``not later than 90 days'' after enactment. The publication of proposed regulations in an NPRM could not govern implementation of the high risk pool program, as they would constitute mere proposals with no force of law. The normal sixtyday public comment period provided for in the case of regulations proposed in an NPRM would by itself consume twothirds of the time the statute provides for implementation. Under these circumstances, it would be impracticable and contrary to the public interest to delay putting regulations into effect that are necessary to implement the program until the rules have been subjected to prior notice and comment procedures.
Therefore, we find good cause to waive the notice of proposed rulemaking and to issue this final rule on an interim basis. We are providing a 60day public comment period. Also, because these regulations need to be in effect in order to undertake full implementation of the program, we also find good cause for waiving the normal delay in effective date that would apply, and these regulations are effective on July 30, 2010.
V. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to provide 60day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues:
We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements (ICRs):
A. ICRs Regarding Proposal Process (Sec. 152.7)
Section 152.7 states that a proposal from a State or from a nonprofit private entity shall demonstrate that the eligible entity has the capacity and technical capability to perform all functions necessary for the design and operation of a PreExisting Condition Insurance Plan (PCIP), and that its proposed PCIP is in full compliance with all of the requirements of this part. Specifically, the proposal shall demonstrate that the proposed PCIP satisfies at least the conditions listed at Sec. 152.7(a)(1) through (9).
If there are States that do not submit acceptable proposals as described in Sec. 152.7, HHS will solicit proposals from nonprofit entities to contract with HHS to operate a PCIP in those States. Nonprofits may submit proposals to contract directly with HHS to operate a PCIP program.
The burden associated with this requirement is the time and effort necessary for a State or nonprofit entity to develop and submit a proposal to operate a PCIP, which is a onetime information collection burden. We estimate that it would take a State or nonprofit entity 684 hours to compile the necessary information to comply with this requirement. While this onetime requirement is subject to the PRA, the associated burden is approved under OMB control number 09381085. B. ICRs Regarding Eligibility (Sec. 152.14)
Section 152.14 discusses eligibility to enroll in a PCIP program.
An individual who enrolls in a PCIP must meet both the requirements
listed at Sec. 152.14(a)(1), demonstrating they are a citizen or
national of the United States or lawfully present in the United States
and Sec. 152.14(a)(3), providing evidence that they have a pre
existing condition as established under paragraph (c) of this section.
The burden associated with this requirement includes the process of
obtaining such information and forwarding the information to the
appropriate party at the PCIP. We estimate this information could be
submitted either electronically or hard copy in accordance with
directions furnished by the PCIP and approved by HHS. We estimate that
it will take approximately 30 minutes per applicant to obtain, review
and submit the above proof(s) of eligibility. Although the Department
has not estimated program participation, for the purpose of this
calculation, we assume that within the first six months of the program
approximately 100,000 potential enrollees will submit eligibility
information to the PCIP program. The estimated onetime burden
associated with this requirement is 50,000 hours. As the program
progresses beyond 2010, we assume that we will receive fewer inquiries
based on the experience with existing State high risk pool programs. In
2011 and beyond, we assume that approximately 50,000 potential
enrollees will submit eligibility information to the PCIP program. The
estimated annual burden associated with this requirement is 25,000 hours.
C. ICRs Regarding Enrollment and Disenrollment Process (Sec. 152.15)
Section 152.15(a) and (b) require a PCIP to develop and implement enrollment and disenrollment processes, respectively. The burden associated with these requirements is the time and effort necessary for a PCIP program to establish enrollment and disenrollment procedures. The burden associated with the establishment of enrollment and disenrollment procedures is a onetime burden that was included in the 684 burden hour estimate in our earlier discussion of Sec. 152.7. While these requirements are subject to the PRA, the associated burden is approved under OMB control number 09381085.
In regards to ongoing reporting under the PCIP contract, any State
or entity selected to administer the PCIP program may later decide it
is in the best interest of their State to propose amendments to [[Page 45023]]
the previously agreed upon contract. We estimate that, while uncommon, such instances may occur and permissible proposed changes would be allowed. When considering all aspects of the contract, which would include the enrollment and disenrollment process, access to services, and the appeals process, we estimate that it will take approximately 24 hours per contractor to submit a revised proposal and implement any approved amendments. The estimated annual burden associated with this requirement is 1,224 hours at a cost of $28,152.
D. ICRs Regarding Access to Services (Sec. 152.22)
Section Sec. 152.22(a) states that a PCIP may specify the networks of providers from whom enrollees may obtain plan services. The PCIP must demonstrate to HHS that it has a sufficient number and range of providers to ensure that all covered services are reasonably available and accessible to its enrollees. The burden associated with this requirement is the time and effort necessary for a PCIP to demonstrate to HHS that it has a sufficient number and range of providers to ensure that all covered services are reasonably available and accessible to its enrollees. The burden associated with these requirements is included in the 684 burden hour estimate for compiling the necessary information to comply with this requirement as stated in our earlier discussion of Sec. 152.7.
In regards to ongoing reporting under the PCIP contract, any State or entity selected to administer the PCIP program may later decide it is in the best interest of their state to propose amendments to the previously agreed upon contract. We estimate that while uncommon, such instances may occur, and permissible proposed changes would be allowed. When considering all aspects of the contract, which would include access to covered services, we estimate that it will take approximately 24 hours per contractor to submit a revised proposal and implement any approved amendments. The estimated annual burden associated with this requirement is 1,224 hours at a cost of $28,152.
E. ICRs Regarding Appeals Procedures (Sec. 152.26)
Section 152.26(a) requires a PCIP to establish and maintain procedures for individuals to appeal eligibility and coverage determinations. Section 152.26(b) lists the minimum requirements for appeals procedures. The burden associated with this requirement is the time and effort necessary for a PCIP to develop and maintain appeals procedures. The burden associated with th
FOR FURTHER INFORMATION CONTACT
Ariel Novick, (301) 492-4290.