This document is scheduled to be published in the

Federal Register on 03/19/2014 and available online at

http://federalregister.gov/a/2014-06031, and on FDsys.gov

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

45 CFR Part 156 

[CMS-9943-IFC] 

RIN 0938-AS28 

Patient Protection and Affordable Care Act; Third Party Payment of Qualified Health 

Plan Premiums 

AGENCY: Centers for Medicare and Medicaid Services, Department of Health and Human 

Services (HHS). 

ACTION: Interim final rule with comment period. 

SUMMARY: This interim final rule requires issuers of qualified health plans (QHPs), including 

stand-alone dental plans (SADPs), to accept premium and cost-sharing payments made on behalf 

of enrollees by the Ryan White HIV/AIDS Program, other Federal and State government 

programs that provide premium and cost sharing support for specific individuals, and Indian 

tribes, tribal organizations, and urban Indian organizations. 

DATES: Effective Date: This interim final rule is effective on [OFR—Insert date of public 

inspection at OFR]. 

Comment date: To be assured consideration, comments must be received at one of the 

addresses provided below, no later than 5 p.m. on [OFR—Insert date 60 days from the date of 

public inspection at the OFR]. 

ADDRESSES: In commenting, please refer to file code CMS–9943–IFC. Because of staff and 

resource limitations, we cannot accept comments by facsimile (FAX) transmission. You may 

submit comments in one of four ways (please choose only one of the ways listed). 
CMS-9943-IFC 2 

1. Electronically. You may submit electronic comments on this regulation to 

http://www.regulations.gov. Follow the ‘‘Submit a comment’’ instructions. 

2. By regular mail. You may mail written comments to the following address ONLY: 

Centers for Medicare & Medicaid Services, Department of Health and Human Services, 

Attention: CMS–9943–IFC, P.O. Box 8016, Baltimore, MD 21244–8016. Please allow 

sufficient time for mailed comments to be received before the close of the comment period. 

3. By express or overnight mail. You may send written comments to the following 

address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human 

Services, Attention: CMS–9943–IFC, Mail Stop C4–26–05, 7500 Security Boulevard, Baltimore, 

MD 21244–1850. 

4. By hand or courier. Alternatively, you may deliver (by hand or courier) your written 

comments ONLY to the following addresses prior to the close of the comment period: 

a. For delivery in Washington, DC—Centers for Medicare & Medicaid 

Services, Department of Health and Human Services, Room 445–G, Hubert H. Humphrey 

Building, 200 Independence Avenue SW, Washington, DC 20201. (Because access to the 

interior of the Hubert H. Humphrey Building is not readily available to persons without 

federal government identification, commenters are encouraged to leave their comments in the 

CMS drop slots located in the main lobby of the building. A stamp-in clock is available for 

persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the 

comments being filed.) 

b. For delivery in Baltimore, MD—Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 

21244-1850. If you intend to deliver your comments to the Baltimore address, call telephone 
CMS-9943-IFC 3 

number (410) 786–7195 in advance to schedule your arrival with one of our staff members. 

Comments erroneously mailed to the addresses indicated as appropriate for hand or courier 

delivery may be delayed and received after the comment period. For information on viewing 

public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: Leigha Basini, (301) 492-4380 for questions 

related to this rule. 

SUPPLEMENTARY INFORMATION: 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 also will be 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 1–800–743–3951. 

I. Background 

The Patient Protection and Affordable Care Act (Pub. L. 111–148) was enacted on 

March 23, 2010. The Health Care and Education Reconciliation Act of 2010 (Pub. L. 111–152), 

which amended and revised several provisions of the Patient Protection and Affordable Care Act, 

was enacted on March 30, 2010. In this final rule, we refer to the two statutes collectively as the 

“Affordable Care Act.” 
CMS-9943-IFC 4 

As of October 1, 2013, for coverage that started as early as January 1, 2014, qualified 

individuals and qualified employers have been able to enroll in QHPs and SADPs – private 

health and dental insurance that has been certified as meeting certain standards – through 

competitive Marketplaces called “Exchanges” or “health insurance Marketplaces.” The word 

“Exchanges” refers to both State Exchanges, also called State-based Exchanges (SBEs), and 

Federally-facilitated Exchanges (FFEs). In this final rule, when we refer to “FFEs,” we are also 

referring to State Partnership Exchanges. CMS has implemented Affordable Care Act provisions 

through regulations codified in title 45 of the Code of Federal Regulations (CFR), and, unless 

otherwise indicated, all regulatory references herein are to that title. 

In the individual market Exchanges, premium and cost-sharing payment arrangements are 

generally managed directly between QHP and SADP issuers and enrollees. For those QHP 

enrollees eligible for advance payments of the premium tax credit and cost-sharing reductions, 

the federal government makes applicable payments to QHP issuers. 

CMS has issued “Frequently Asked Questions” or “FAQs” with respect to premium and 

cost-sharing payments made by third parties on behalf of QHP enrollees. In a FAQ issued on 

November 4, 2013 (the November FAQ),1 CMS encouraged QHP issuers not to accept thirdparty payments from hospitals, other healthcare providers, and other commercial entities due to 

concerns that such practices could skew the insurance risk pool and create an unlevel field in the 

Exchanges. 

On February 7, 2014, CMS issued additional FAQs (the February FAQs) clarifying that 

the November FAQ was not intended to discourage QHP issuers from accepting third party 

premium and cost-sharing payments made by Indian tribes, tribal organizations, and urban Indian 

 

1

 http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/third-party-qa-11-04-2013.pdf. 
CMS-9943-IFC 5 

organizations, as well as by state and federal government programs (such as the Ryan White 

HIV/AIDS Program).2

 CMS affirmatively encouraged QHP issuers to accept such payments 

given that federal or state law or policy specifically envisions third party payment of premium 

and cost-sharing amounts by these entities. 

Specifically, the Ryan White HIV/AIDS Program plays a critical role in ensuring that 

people living with HIV in the United States have access to life-saving antiretroviral medications, 

serving over 550,000 people living with HIV annually. Medication access is provided through 

both payment for medication and payment of insurance premiums and cost-sharing when such 

assistance is cost effective for the Ryan White HIV/AIDS Program. The Ryan White HIV/AIDS 

Program has been authorized to provide insurance assistance for low-income people living with 

HIV since 1990 under section 2615 of the Public Health Service Act, as added by the Ryan 

White Comprehensive AIDS Resources Emergency (CARE) Act (Pub. L. 101–381, title II, §201, 

Aug. 18, 1990). Section 2616(f) of the Public Health Service Act provides authority for states to 

use AIDS Drug Assistance Program grant funds to purchase or maintain health insurance or 

plans when the coverage includes the relevant therapeutics and the cost of such coverage does 

not exceed the costs of otherwise providing them directly. This provision was added in 2000 as 

subsection (e) by the Ryan White CARE Act Amendments of 2000 (Pub. L. 106-345, §204(b)) 

and was subsequently renumbered to (f) in 2006. Through Policy Notices 99-01, 7-05, and most 

recently 13-04, 13-05 and 13-06, the Health Resources and Services Administration HIV/AIDS 

Bureau has provided guidance to grantees reiterating that the funds awarded under the Parts A, 

B, and C of the Ryan White HIV/AIDS Program may be used to support a health insurance 

premium and costs-sharing assistance program as a core medical service for eligible low-income 

 

2

 http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/third-party-payments-of-premiums-forqualified-health-plans-in-the-marketplaces-2-7-14.pdf. 
CMS-9943-IFC 6 

people living with HIV when it is cost-effective for the program. Ryan White HIV/AIDS 

Program funds are payer-of-last-resort funds and may be used for public or private health 

insurance premiums, as well as cost-sharing (for example, deductibles, copayments, and 

coinsurance). In fiscal year 2013, the Ryan White HIV/AIDS Program AIDS Drug Assistance 

Program paid $397,245,305 in premium assistance to issuers on behalf of program beneficiaries. 

As of June 2013, the Ryan White HIV/AIDS Program AIDS Drug Assistance Program provided 

premium assistance for 52,568 people living with HIV. These premium assistance expenditures 

were paid directly to issuers. 

In addition, section 1312 of the Affordable Care Act, section 402 of the Indian Health 

Care Improvement Act, and 45 CFR 155.240(b) provides that Exchanges may permit Indian 

tribes, tribal organizations, and urban Indian organizations to pay aggregated QHP premiums on 

behalf of qualified individuals, subject to terms and conditions determined by the Exchange. 

In the past, a number of tribes have provided premium assistance to tribal members eligible to 

enroll in the Medicare Part D program. These arrangements have resulted in an increase in the 

number of tribal members enrolled in Medicare Part D. Building from that experience, these 

same arrangements are being replicated by tribes and tribal organizations in providing premium 

assistance to qualified individuals for QHPs in the Exchanges. Under these arrangements tribes 

aggregate premium payments to issuers and reduce their administrative costs. 

II. Provisions of the Interim Final Rule 

 We have become aware that, despite related policy clarifications, some QHP issuers 

continue to reject payments of premium and cost sharing by the Ryan White HIV/AIDS 

Program. In particular, this QHP issuer practice is causing access problems for persons who rely 

on the Ryan White HIV/AIDS Program for assistance. Accordingly, we are promulgating a new 
CMS-9943-IFC 7 

requirement at §156.1250 that QHP and SADPs must accept third party premium and cost 

sharing payments from the Ryan White HIV/AIDS Program. 

 To ensure that individuals reliant on programs similar to the Ryan White HIV/AIDS 

Program are not being adversely affected by QHPs’ and SADPs’ refusal to accept third party 

premium and cost-sharing payments, we are including within the new requirement that QHPs 

and SADPs must accept third party premium and cost-sharing payments from the following other 

entities in addition to the Ryan White HIV/AIDS Program: Indian tribes, tribal organizations, 

and urban Indian organizations; and state and federal government programs. This standard 

applies to all individual market QHPs and SADPs, regardless of whether they are offered 

through an FFE, an SBE, or outside of the Exchanges. 

 Our new standard does not prevent QHPs and SADPs from having contractual 

prohibitions on accepting payments of premium and cost sharing from third party payers other 

than those specified in this interim final regulation. In particular, as stated in our November 

FAQ, we remain concerned that third party payments of premium and cost sharing provided by 

hospitals, other healthcare providers, and other commercial entities could skew the insurance risk 

pool and create an unlevel competitive field in the insurance market. We continue to discourage 

such third party payments of premiums and cost sharing, and we encourage QHPs and SADPs to 

reject these payments. 

 We are also amending §156.805 to ensure that new §156.1250 can be enforced. 

Enforcement of FFE issuer standards and requirements is governed by §156.800 through 

§156.810. In the August 30, 2013 Program Integrity Rule (78 FR 54070, 54143), we established 

the bases for HHS to impose civil money penalties (CMPs) against QHP issuers for violations of 

certain standards applicable to issuers offering QHPs in the FFEs. In §156.805(a), we set forth 
CMS-9943-IFC 8 

the grounds for imposing CMPs. Since the publication of that final rule, we noted that certain 

paragraphs under these sections should be clarified and, in some instances, technical corrections 

are necessary, to properly reflect when these enforcement remedies will apply. These 

clarifications and corrections are specifically necessary to reflect that these enforcement 

remedies will apply to violations of §156.1250. For example, under paragraph (1), the word 

“including” was inadvertently omitted from the phrase “misconduct in the Federally-facilitated 

Exchange or substantial non-compliance with the Exchange standards applicable to issuers 

offering QHPs in the Federally-facilitated Exchange [including] under subparts C through G of 

part 153 of this subchapter.” This same phrase also inadvertently referenced specific subparts 

within part 153, including subparts C and D, which contain standards and requirements for States 

in relation to the reinsurance and risk adjustment programs. We are therefore amending 

paragraph (1) so that it correctly provides that §156.805 targets violations of issuer standards and 

requirements of part 153 that are applicable to issuers. We are also making changes to clarify 

that substantial non-compliance with any Exchange standard or requirement applicable to issuers 

in the FFE is grounds for imposing CMPs and that reference to specific subparts of part 153 was 

not intended to be limit the types of QHP standards and requirements for which enforcement 

under this section would be available. We are further amending paragraph (1) to add an explicit 

reference to part 156, to clarify that substantial non-compliance with the Exchange standards 

applicable to issuers offering QHPs in the FFEs under part 156, including new §156.1250, may 

be a basis for the imposition of CMPs under §156.805. 

Accordingly, failure to comply with the requirement to accept third party payments in 

accordance with §156.1250 could constitute a violation of §156.805(a)(1) as “substantial noncompliance with [an] Exchange standard[].” Depending upon the circumstances, a QHP or 
CMS-9943-IFC 9 

SADP issuer’s failure to comply with §156.1250 could also fall under §156.805(a)(4) as a 

“practice that would reasonably be expected to have the effect of denying or discouraging 

enrollment into a QHP offered by the issuer (except as permitted by this part) by qualified 

individuals whose medical condition or history indicates the potential for a future need for 

significant medical services or items.” Under §156.805(c), an issuer offering a QHP or SADP 

through an FFE may be subject to a maximum penalty of $100 per day, per each individual who 

is adversely affected by the QHP or SADP issuer's non-compliance. 

Issuers offering QHPs or SADPs through an SBE or outside of the Exchanges would be 

subject to any penalties that the SBE or the state has established to address issuer noncompliance with general QHP and SADP standards and requirements under part 156, Subpart M, 

in addition to any other SBE-specific or state-specific enforcement. 

Qualified individuals in states with an FFE or SPE who are affected by a QHP’s or 

SADP’s violation of this new requirement, either because they are unable to effectuate coverage 

because an issuer will not accept the third party premium payments which the individual needs to 

be able to make a complete payment of the premium within the open enrollment time frame, or 

because they lose coverage due to the issuer’s refusal to accept the required third-party premium 

or cost-sharing payments from entities described in 45 CFR 156.1250, may be eligible for an 

FFE special enrollment period (SEP) in accordance with §155.420(d)(9) and a certificate of 

exemption under §155.605(g)(1)(iii). CMS will issue additional guidance in the near future 

clarifying the specific criteria for obtaining the SEP or hardship exemption. We also encourage 

all SBEs to grant an SEP and certificate of exemption under these circumstances. 
CMS-9943-IFC 10 

We continue to consider making additional regulatory changes to QHP and SADP issuer 

responsibilities to ensure that QHPs and SADPs accept third party premium and cost-sharing 

payments from the Ryan White HIV/AIDS Program, other state and federal government 

programs that support premium and cost sharing, and Indian tribes, tribal organizations, and 

urban Indian organizations. 

III. Waiver of Proposed Rulemaking and Waiver of Delay in Effective Date 

We ordinarily publish a notice of proposed rulemaking 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 at least thirty days later. This 

procedure can be waived, however, if an agency finds good cause that a notice-and-comment 

procedure is impracticable, unnecessary, or contrary to the public interest and incorporates a 

statement of the finding and its reasons in the rule issued. CMS for good cause, under 5 U.S.C. 

553(b)(B), finds that the notice-and-comment requirements of the Administrative Procedure Act 

(APA) would be impracticable and contrary to the public interest given that a delay in coverage 

for people who rely on one of the third parties noted in the regulation to pay their premiums 

could result in worsening medical conditions. Further, there is risk that one or more issuers may 

discontinue the existing QHP coverage of HIV/AIDS patients who are dependent on the Ryan 

White HIV/AIDS Program for premium assistance in the near future. Based on these same 

concerns, we find for good cause, under 5 U.S.C. 553(b)(B), that the notice-and-comment 

requirements of the APA would be impracticable and contrary to the public interest with respect 

the clarification and correction of our enforcement authority at §156.805(a). For the reasons 

outlined above, the public interest requires that new §156.1250 be immediately enforced. 
CMS-9943-IFC 11 

Additionally, section 553(d) of the APA (5 U.S.C. 553(d)) ordinarily requires that a final 

rule be effective not less than 30 days from the date of their publication in the Federal Register. 

This 30-day delay in effective date can be waived, however, if otherwise provided by an agency 

for good cause found and published with the rule. For the reasons set forth below, we also find 

good cause to waive the 30-day delay in effective date as unnecessary, impracticable and 

contrary to the public interest. 

In this case, given the short timeframe under which this change must be implemented, 

delaying the promulgation and effectiveness of this rule would mean that some people who are 

eligible to enroll in a QHP but rely on the Ryan White HIV/AIDs Program, tribes and tribal 

organizations, or other state or federal programs to contribute to the cost of the premium, either 

in whole or in part, would not be able to effectuate their coverage. It could also mean that the 

third parties noted in the regulation would not be able to assist people who are already enrolled 

but do not have the funds to continue to pay their premiums, which could lead to coverage 

terminations for failure to pay premiums. Both of these scenarios could result in people’s 

medical conditions worsening and an increase in uncompensated care. We consider this policy 

to be a benefit to consumers. Recent studies have demonstrated that individuals with HIV on 

antiretroviral medications who achieve viral load suppression are less likely to transmit HIV to 

others.3

 Ensuring access to care and treatment services support the achievement of viral 

suppression, and, therefore, has a significant public health impact on HIV incidence as well. 

The full scope of this issue and the need for §156.1250 was not known until after open 

enrollment began on October 1, 2013. We assumed that issuers of QHPs and SADPs would 

 

3

 Myron S. Cohen, Marybeth McCauley, and Theresa R. Gamble, HIV treatment as prevention and HPTN 052, 

Current Opinion in HIV and AIDS, Volume 7(2), p. 99-105 (March 2012); William Miller, Kimberly Powers, M. 

Kumi Smith, Myron S Cohen, Community viral load as a measure for assessment of HIV treatment as prevention, 

Lancet Infect Dis 13:459-64 (2013). 
CMS-9943-IFC 12 

continue to accept these payments as these issuers had done prior to the availability of coverage 

through the Exchanges, and thus the impact of such third party payments was built into their 

baselines.4 Indeed, we expect that the vast majority of issuers already have been accepting these 

payments with this understanding. Similarly, with respect to the clarification of and correction to 

our enforcement authority at §156.1280(a), waiver of the 30-day-delay in effective date is 

necessary to enable CMS to take immediate enforcement action as necessary against those 

issuers who continue to refuse to accept the referenced third party payments. As described 

above, these actions could interfere with the ability of at-risk individuals to effectuate or 

maintain coverage. 

Given the unusual circumstances and for the reasons outlined above, CMS finds good 

cause under the APA, 5 U.S.C. 553(b)(B) and (d)(3), to waive notice-and-comment rulemaking 

and to waive the delay in effective date and proceed directly with the issuance of a final rule with 

an immediate effective date. 

IV. Collection of Information Requirements 

This rule does not impose new or alter existing information collection and recordkeeping 

requirements. Consequently, it need not be reviewed by the Office of Management and Budget 

under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35). 

V. Regulatory Impact Analysis 

We have examined the impact of this final rule as required by Executive Order 12866 on 

Regulatory Planning and Review (September 30, 1993) and Executive Order 13563 on 

Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act 

 

4

 For this reason, we do not believe that the new requirement in §156.1250 will have a material effect on the risk 

pools of QHP and SADP issuers. Further, starting in 2014, the risk adjustment, transitional reinsurance, and risk 

corridor programs offer new protection to issuers in the individual market against adverse selection. 
CMS-9943-IFC 13 

(RFA) (September 19, 1980, Pub. L. 96-354), section 202 of the Unfunded Mandates Reform 

Act of 1995 (March 22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism 

(August 4, 1999), and the Congressional Review Act (5 U.S.C. 804(2)). 

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of 

available regulatory alternatives and, if regulation is necessary, to select regulatory approaches 

that maximize net benefits (including potential economic, environmental, public health and 

safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be 

prepared for major rules with economically significant effects ($100 million or more in any 

1 year). It is CMS’s belief that this final rule does not reach this economic threshold and thus is 

not considered a major rule. 

This rule requires individual market QHPs and SADPs to accept premium payments 

made by certain third parties. The rule would also require individual market QHPs and SADPs 

to accept cost-sharing payments made by these third parties. We do not believe these actions 

would impose any significant new costs on issuers because we assume that the vast majority of 

issuers already accept such payments. 

A. Regulatory Flexibility Act

The Regulatory Flexibility Act (5 U.S.C. 601 et seq.) (RFA) requires agencies to prepare 

an initial regulatory flexibility analysis to describe the impact of the rule on small entities, unless 

the head of the agency can certify that the rule would not have a significant economic impact on 

a substantial number of small entities. Agencies must analyze options for regulatory relief for 

small businesses if a rule has a significant impact on a substantial number of small entities. The 

RFA generally defines a “small entity” as--(1) a proprietary firm meeting the size standards of 

the Small Business Administration (SBA); (2) a not-for-profit organization that is not dominant 
CMS-9943-IFC 14 

in its field; or (3) a small government jurisdiction with a population of less than 50,000. States 

and individuals are not included in the definition of “small entity.” CMS uses as its measure of 

significant economic impact on a substantial number of small entities a change in revenues of 

more than 3 percent. For the purposes of the regulatory flexibility analysis, we expect issuers 

offering individual market QHPs and SADPs operating in an FFE, an SBE or outside of the 

exchange to be affected by this proposed rule. 

As discussed in Health Insurance Issuers Implementing Medical Loss Ratio (MLR) 

Requirements under the Patient Protection and Affordable Care Act; Interim Final Rule,5 few, if 

any, issuers are small enough to fall below the size thresholds for small business established by 

the SBA. In that rule, we used a data set created from 2009 NAIC Health and Life Blank annual 

financial statement data to develop an updated estimate of the number of small entities that offer 

comprehensive major medical coverage in the individual and group markets. For purposes of 

that analysis, CMS used total Accident and Health earned premiums as a proxy for annual 

receipts. We estimated that there are 28 small entities with less than $7 million in accident and 

health earned premiums offering individual or group comprehensive major medical coverage.6

 

However, this estimate may overstate the actual number of small health insurance issuers 

offering such coverage, since it does not include receipts from these companies’ other lines of 

business. 

 

5 Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements under the Patient Protection and 

Affordable Care Act; Interim Final Rule, 75 Federal Register 74864, 74918-20 (December 1, 2010) (codified at 45 

C.F.R. Part 158).

6 According to SBA size standards, entities with average annual receipts of $7 million or less would be considered 

small entities for North American Industry Classification System (NAICS) Code 524114 (Direct Health and Medical 

Insurance Carriers). For more information, see ‘‘Table of Size Standards Matched to North American Industry 

Classification System Codes,’’ effective March 26, 2012, U.S. Small Business Administration, available at 

http://www.sba.gov. 
CMS-9943-IFC 15 

Therefore, we are not preparing an analysis for the RFA because we have determined, 

and the Secretary certifies, that this final rule will not have a significant economic impact on a 

substantial number of small entities. 

B. Unfunded Mandates

Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) requires that 

agencies assess anticipated costs and benefits and take certain other actions before issuing a 

proposed rule (and subsequent final rule) that includes any federal mandate that may result in 

expenditures in any one year by a state, local, or tribal governments, in the aggregate, or by the 

private sector, of $100 million in 1995 dollars, updated annually for inflation. In 2014, that 

threshold is approximately $141 million. UMRA does not address the total cost of a rule. 

Rather, it focuses on certain categories of costs, mainly those “federal mandate” costs resulting 

from: (1) imposing enforceable duties on State, local, or tribal governments, or on the private 

sector; or (2) increasing the stringency of conditions in, or decreasing the funding of, state, local, 

or tribal governments under entitlement programs. 

This final rule requires QHPs and SADPs to accept premiums paid by certain third 

parties. Many issuers currently have systems in place to accept premium payments as part of the 

normal course of business, including payments made by people other than the insured. For 

example, the Ryan White HIV/AIDS Program AIDS Drug Assistance Program provided 

$397,245,000 in premium assistance to issuers on behalf of Ryan White HIV/AIDS Program 

participants during fiscal year 2013. In June 2013, the Ryan White HIV/AIDS Program AIDS 

Drug Assistance Program provided premium assistance for 52,568 people living with HIV. 

These premium assistance expenditures were paid directly to issuers. Accordingly, this rule 

generally should not impose any significant new administrative costs on issuers. CMS has 
CMS-9943-IFC 16 

concluded that this rule does not place any mandates on state, local, or tribal governments or the 

private sector that exceed the threshold for 2014. 

C. Federalism

Executive Order 13132 establishes certain requirements that an agency must meet when it 

promulgates a proposed rule (and subsequent final rule) that imposes substantial direct costs on 

state and local governments, preempts state law, or otherwise has federalism implications. This 

rule does not impose any costs on state or local governments not otherwise imposed by alreadyfinalized provisions of the regulations implementing the Affordable Care Act. 

In compliance with the requirement of Executive Order 13132 that agencies examine 

closely any policies that may have federalism implications or limit the policy-making discretion 

of the states, CMS has engaged in efforts to consult with and work cooperatively with affected 

states, including participating in conference calls with and attending conferences of the NAIC, 

and consulting with State insurance officials on an individual basis. We believe that this rule 

does not impose substantial direct costs on state and local governments, preempt state law, or 

otherwise have federalism implications. We are amending the operational requirements for 

QHPs and SADPs. Under the requirements set forth in section 8(a) of Executive Order 13132, 

and by the signatures affixed to this regulation, the Department of Health and Human Services 

certifies that CMS has complied with the requirements of Executive Order 13132 for the attached 

proposed regulation in a meaningful and timely manner. 

In accordance with the provisions of Executive Order 12866, this regulation was 

reviewed by the Office of Management and Budget. 
CMS-9943-IFC 17 

D. Congressional Review Act

The Congressional Review Act, 5 U.S.C. 801, et seq., as added by the Small Business 

Regulatory Enforcement Fairness Act of 1996, generally provides that before a rule may take 

effect, the agency promulgating the rule must submit a rule report, which includes a copy of the 

rule, to each House of the Congress and to the Comptroller General of the United States. We 

will submit a report containing this rule and other required information to the U.S. Senate, the 

U.S. House of Representatives, and the Comptroller General of the United States prior to 

publication of the rule in the Federal Register

List of Subjects in 45 CFR Part 156

Administrative appeals, Administrative practice and procedure, Administration and 

calculation of advance payments of premium tax credit, Advertising, Advisory Committees, 

Brokers, Conflict of interest, Consumer protection, Cost-sharing reductions, Grant programshealth, Grants administration, Health care, Health insurance, Health maintenance organization 

(HMO), Health records, Hospitals, American Indian/Alaska Natives, Individuals with 

disabilities, Loan programs-health, Organization and functions (Government agencies), 

Medicaid, Payment and collections reports, 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 

amends 45 CFR part 156 as set forth below: 

PART 156—HEALTH INSURANCE ISSUER STANDARDS UNDER THE 

AFFORDABLE CARE ACT, INCLUDING STANDARDS RELATED TO EXCHANGES 

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

Authority: Title I of the Affordable Care Act, sections 1301–1304, 1311–1313, 1321-

1322, 1324, 1334, 1342–1343, 1401–1402, Pub. L. 111-148, 124 Stat. 119 

42 U.S.C. 18021-18024, 18031-18032, 18041-18042, 18044, 18054, 18061, 18063, 18071, 

18082, 26 U.S.C. 36B, and 31 U.S.C. 9701). 

2. Section 156.805 is amended by revising paragraph (a)(1) to read as follows: 

§156.805 Bases and process for imposing civil money penalties in Federally-facilitated 

Exchanges. 

(a) * * * 

(1) Misconduct in the Federally-facilitated Exchange or substantial non-compliance with 

the Exchange standards and requirements applicable to issuers offering QHPs in the Federallyfacilitated Exchange, including but not limited to issuer standards and requirements under parts 

153 and 156 of this subchapter; 

* * * * * 

3. Section 156.1250 is added to read as follows: 

§156.1250 Acceptance of certain third party payments. 

Issuers offering individual market QHPs, including stand-alone dental plans, must accept 

premium and cost-sharing payments from the following third-party entities on behalf of plan 

enrollees: 
CMS-9943-IFC 19 

(a) Ryan White HIV/AIDS Program under title XXVI of the Public Health Service Act; 

(b) Indian tribes, tribal organizations or urban Indian organizations; and 

(c) State and Federal Government programs. 

Dated: March 11, 2014 

 _______________________________ 

Marilyn Tavenner, 

Administrator, 

 Centers for Medicare & Medicaid Services. 

Approved: March 12, 2014 

 __________________________________ 

Kathleen Sebelius, 

Secretary, 

Department of Health and Human Services. 

BILLING CODE 4120-01-P 
CMS-9943-IFC 20 

[FR Doc. 2014-06031 Filed 03/14/2014 at 4:15 pm; Publication Date: 03/19/2014]