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Making Progress on Health Insurance Exchanges without Definitive Guidance


Health plans are waiting for CMS (The Centers for Medicare and Medicaid Services) to provide detailed requirements and guidance about participating in federal health insurance exchanges. In the meantime, we believe their leading bet is to refer to the managed care manuals for Medicare Part C and D. Or in the case of a state-run exchange, it probably makes sense to follow the state’s Medicaid guidelines.

When Medicare Part D launched in 2006, it was 18 months before CMS issued definitive guidance about what health plans needed to do, how they needed do it, and what specific requirements had to be met to achieve compliance. Along the way, the guidance was in a constant state of flux. Also, CMS was relatively collaborative during that period — only later shifting its focus to rigorous enforcement.

If history is a useful guide, CMS might follow a similar approach with health insurance exchanges. However, the recent well publicized problems with the Affordable Care Act Website suggest there may likely be a strong emphasis on beneficiary protection and member satisfaction, with CMS focusing extra attention on activities that directly affect the end-customer, including sales and marketing, enrollment and patient care at the point of service. As a precautionary measure, health plans might want to be especially diligent in those areas. Another key area is risk adjustments and payments, because that’s where most of the limited guidance has focused so far.

Self-enforced monitoring could also be especially important during this uncertain time. CMS is allowing bids to include the cost of an independent third-party audit, so health plans might want to build that in as a standard step in the compliance process. At some point, CMS will issue sub-regulatory guidance that defines exactly what needs to be done. But until that happens, health plans need to make an educated guess but keep moving forward.

Kelly Sauders
Deloitte & Touche LLP


As used in this document, “Deloitte” means Deloitte & Touche LLP, a subsidiary of Deloitte LLP. Please see for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting.

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