15240 Federal Register / Vol. 79, No. 53 / Wednesday, March 19, 2014 / Rules and Regulations 

methylethyl)-1-(1H-1,2,4-triazol-1- 

ylmethyl)cyclopentanol) in or on 

vegetable, legume, group 6 at 0.01 ppm. 

EPA is revising the tolerance expression 

for ipconazole to clarify that metabolites 

and degradates are covered by the 

tolerances and to specify how 

compliance with the tolerances is to be 

measured. The existing tolerances for 

pea and bean, dried shelled, except 

soybean, subgroup 6C at 0.01 ppm and 

soybean, seed at 0.01 ppm will be 

removed from paragraph (a) of § 180.646 

as these tolerances are encompassed 

within vegetable, legume, group 6. 

VI. Statutory and Executive Order 

Reviews 

This final rule establishes tolerances 

under FFDCA section 408(d) in 

response to a petition submitted to the 

Agency. The Office of Management and 

Budget (OMB) has exempted these types 

of actions from review under Executive 

Order 12866, entitled ‘‘Regulatory 

Planning and Review’’ (58 FR 51735, 

October 4, 1993). Because this final rule 

has been exempted from review under 

Executive Order 12866, this final rule is 

not subject to Executive Order 13211, 

entitled ‘‘Actions Concerning 

Regulations That Significantly Affect 

Energy Supply, Distribution, or Use’’ (66 

FR 28355, May 22, 2001) or Executive 

Order 13045, entitled ‘‘Protection of 

Children from Environmental Health 

Risks and Safety Risks’’ (62 FR 19885, 

April 23, 1997). This final rule does not 

contain any information collections 

subject to OMB approval under the 

Paperwork Reduction Act (PRA) (44 

U.S.C. 3501 et seq.), nor does it require 

any special considerations under 

Executive Order 12898, entitled 

‘‘Federal Actions to Address 

Environmental Justice in Minority 

Populations and Low-Income 

Populations’’ (59 FR 7629, February 16, 

1994). 

Since tolerances and exemptions that 

are established on the basis of a petition 

under FFDCA section 408(d), such as 

the tolerances in this final rule, do not 

require the issuance of a proposed rule, 

the requirements of the Regulatory 

Flexibility Act (RFA) (5 U.S.C. 601 et 

seq.), do not apply. 

This final rule directly regulates 

growers, food processors, food handlers, 

and food retailers, not States or tribes, 

nor does this action alter the 

relationships or distribution of power 

and responsibilities established by 

Congress in the preemption provisions 

of FFDCA section 408(n)(4). As such, 

the Agency has determined that this 

action will not have a substantial direct 

effect on States or tribal governments, 

on the relationship between the national 

government and the States or tribal 

governments, or on the distribution of 

power and responsibilities among the 

various levels of government or between 

the Federal Government and Indian 

Tribes. Thus, the Agency has 

determined that Executive Order 13132, 

entitled ‘‘Federalism’’ (64 FR 43255, 

August 10, 1999) and Executive Order 

13175, entitled ‘‘Consultation and 

Coordination with Indian Tribal 

Governments’’ (65 FR 67249, November 

9, 2000) do not apply to this final rule. 

In addition, this final rule does not 

impose any enforceable duty or contain 

any unfunded mandate as described 

under Title II of the Unfunded Mandates 

Reform Act of 1995 (UMRA) (2 U.S.C. 

1501 et seq.). 

This action does not involve any 

technical standards that would require 

Agency consideration of voluntary 

consensus standards pursuant to section 

12(d) of the National Technology 

Transfer and Advancement Act of 1995 

(NTTAA) (15 U.S.C. 272 note). 

VII. Congressional Review Act 

Pursuant to the Congressional Review 

Act (5 U.S.C. 801 et seq.), EPA 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. This action is not a ‘‘major 

rule’’ as defined by 5 U.S.C. 804(2). 

List of Subjects in 40 CFR Part 180 

Environmental protection, 

Administrative practice and procedure, 

Agricultural commodities, Pesticides 

and pests, Reporting and recordkeeping 

requirements. 

Dated: March 12, 2014. 

Lois Rossi, 

Director, Registration Division, Office of 

Pesticide Programs. 

Therefore, 40 CFR chapter I is 

amended as follows: 

PART 180—[AMENDED] 

■ 1. The authority citation for part 180 

continues to read as follows: 

Authority: 21 U.S.C. 321(q), 346a and 371. 

■ 2. In § 180.646: 

■ a. Revise the introductory text in 

paragraph (a). 

■ b. Remove ‘‘Pea and bean, dried 

shelled, except soybean, subgroup 6C’’, 

and ‘‘Soybean, seed’’ from the table in 

paragraph (a). 

■ c. Add alphabetically ‘‘Vegetable, 

legume, group 6’’ to the table in 

paragraph (a). 

The amendments read as follows: 

§ 180.646 Ipconazole; tolerances for 

residues. 

(a) General. Tolerances are 

established for residues of ipconazole, 

including its metabolites and 

degradates, in or on the commodities 

listed in the table below. Compliance 

with the tolerance levels specified 

below is to be determined by measuring 

only ipconazole (2-[(4- 

chlorophenyl)methyl]-5-(1- 

methylethyl)-1-(1H-1,2,4-triazol-1- 

ylmethyl)cyclopentanol) in or on the 

commodity. 

Commodity Parts per 

million 

* * * * * 

Vegetable, legume, group 6 0.01 

* * * * * 

[FR Doc. 2014–06059 Filed 3–18–14; 8:45 am] 

BILLING CODE 6560–50–P 

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 March 14, 2014. 

Comment date: To be assured 

consideration, comments must be 

received at one of the addresses 

provided below, no later than 5 p.m. on 

May 13, 2014. 

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 


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1http://www.cms.gov/CCIIO/Resources/FactSheets-and-FAQs/Downloads/third-party-qa-11-04- 

2013.pdf. 

2http://www.cms.gov/CCIIO/Resources/FactSheets-and-FAQs/Downloads/third-partypayments-of-premiums-for-qualified-health-plansin-the-marketplaces-2-7-14.pdf. 

comments in one of four ways (please 

choose only one of the ways listed). 

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 

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.’’ 

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 

third-party 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 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 lifesaving 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– 


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15242 Federal Register / Vol. 79, No. 53 / Wednesday, March 19, 2014 / Rules and Regulations 

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 lowincome 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 costsharing (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 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 

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 Federallyfacilitated 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 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 


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Federal Register / Vol. 79, No. 53 / Wednesday, March 19, 2014 / Rules and Regulations 15243 

3Myron 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). 

4For 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. 

to any other SBE-specific or statespecific 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. 

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-andcomment 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. 

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 

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-daydelay 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 (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 


wreier-aviles on DSK5TPTVN1PROD with RULES
15244 Federal Register / Vol. 79, No. 53 / Wednesday, March 19, 2014 / Rules and Regulations 

5Health 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 CFR Part 158). 

6According 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. 

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 costsharing 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 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. 

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 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 

already-finalized 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. 

D. Congressional Review Act 

The Congressional Review Act, 5 

U.S.C. 801, et seq., as added by the 


wreier-aviles on DSK5TPTVN1PROD with RULES
Federal Register / Vol. 79, No. 53 / Wednesday, March 19, 2014 / Rules and Regulations 15245 

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, Costsharing 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 Federallyfacilitated Exchange or substantial noncompliance with the Exchange 

standards and requirements applicable 

to issuers offering QHPs in the 

Federally-facilitated 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 costsharing payments from the following 

third-party entities on behalf of plan 

enrollees: 

(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. 

[FR Doc. 2014–06031 Filed 3–14–14; 4:15 pm] 

BILLING CODE 4150–01–P 

DEPARTMENT OF TRANSPORTATION 

Federal Motor Carrier Safety 

Administration 

49 CFR Parts 383 and 390 

[Docket No. FMCSA–2012–0156] 

RIN 2126–AB70; Formerly RIN 2126–AB53 

Gross Combination Weight Rating; 

Definition 

AGENCY: Federal Motor Carrier Safety 

Administration (FMCSA), DOT. 

ACTION: Final rule. 

SUMMARY: FMCSA amends the Federal 

Motor Carrier Safety Regulations 

(FMCSRs) by revising the definition of 

‘‘gross combination weight rating’’ (or 

GCWR) to clarify the applicability of the 

Agency’s safety regulations for singleunit trucks (vehicles other than truck 

tractors) when they are towing trailers, 

and the GCWR information is not 

included on the vehicle manufacturer’s 

certification label. 

DATES: The final rule is effective April 

18, 2014. 

ADDRESSES: For access to the docket to 

read background documents, including 

those referenced in this document, or to 

read comments received, go to http://

www.regulations.gov at any time and 

insert ‘‘FMCSA–2012–0156’’ in the 

‘‘Keyword’’ box, and then click 

‘‘Search.’’ The docket is also available 

by going to the ground floor, Room 

W12–140, DOT Building, 1200 New 

Jersey Avenue SE., Washington, DC, 

between 9 a.m. and 5 p.m., e.t., Monday 

through Friday, except Federal holidays. 

FOR FURTHER INFORMATION CONTACT: Mr. 

Gary Siekmann, Office of Enforcement, 

Federal Motor Carrier Safety 

Administration, 1200 New Jersey 

Avenue SE., Washington, DC 20590– 

0001, by telephone at (202) 493–0442 or 

via email at Garry.Siekmann@dot.gov. 

Office hours are from 9 a.m. to 5 p.m. 

e.t., Monday through Friday, except 

Federal holidays. If you have questions 

on viewing material in the docket, 

contact Docket Operations (202) 366– 

9826. 

SUPPLEMENTARY INFORMATION: 

I. Executive Summary 

Purpose and Summary of the Major 

Provisions 

This rule clarifies the applicability 

and improves the enforceability of the 

safety regulations by redefining GCWR. 

This revised definition provides a 

uniform means for motor carriers, 

drivers, and enforcement officials to 

determine whether a driver operating a 

combination vehicle is subject to the 

commercial driver’s license (CDL) 

requirements (49 CFR Part 383) or the 

general safety requirements (49 CFR Part 

390). This rule also responds to a 

petition filed by the Commercial 

Vehicle Safety Alliance (CVSA) on 

February 14, 2008, seeking changes in 

the definition of ‘‘gross combination 

weight rating.’’ 

Benefits and Costs 

This action only clarifies the 

definition of GCWR to eliminate 

confusion surrounding the language of 

the previous definition and longstanding enforcement practices. The 

rule provides clear criteria for 

determining the applicability of the 

FMCSRs when the GCWR is the 

deciding factor. Costs, if any, will be 

borne by motor carriers and drivers who 

had previously concluded, based on the 

wording of the GCWR definition, that 

their operations were not subject to 

certain safety regulations, but now will 

comply with the applicable rules. 


wreier-aviles on DSK5TPTVN1PROD with RULES