Federal PHS Act Market Conduct Examinations Center for Consumer - - PowerPoint PPT Presentation

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Federal PHS Act Market Conduct Examinations Center for Consumer - - PowerPoint PPT Presentation

Nov 12, 2023 317 likes •396 views

Federal PHS Act Market Conduct Examinations Center for Consumer Information & Insurance Oversight (CCIIO) Oversight Group Centers for Medicare & Medicaid Service s(CMS) Department of Health and Human Services (HHS) May 27, 2015

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CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Federal PHS Act Market Conduct Examinations

Center for Consumer Information & Insurance Oversight (CCIIO) – Oversight Group

Centers for Medicare & Medicaid Service s(CMS) Department of Health and Human Services (HHS) May 27, 2015

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CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Market Conduct Exam Overview

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  • Exam process recommended by the NAIC and

used by State DOIs

  • Examine issuers in Direct Enforcement states or

non-federal governmental plans to verify compliance with PHS Act requirements

  • Authority: 45 C.F.R. § 150.313 Market Conduct

Examinations

  • Using a combination of CCIIO contractors and

Compliance & Enforcement Division resources

– State regulators will have a direct contact at CCIIO

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CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Exam Timeline

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  • CCIIO Compliance & Enforcement team will

generate a list of examinees based on:

– complaints, – information from interested parties, – recommendations/requests from regulators, – other sources

  • State regulators will be notified in advance of

intent to call an issuer exam in a Direct Enforcement state

– State in which issuer markets product – State of domicile

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CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Exam Timeline (cont)

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  • Exam Call letter

– 30 days before exam begins – Requests designated contact – Indicates type of exam (targeted vs. comprehensive, desk

  • vs. on-site)
  • Data call letter

– Identifies examiner-in-charge – Lists items needed for exam

  • Pre-exam conference

– Clarifies expectations – Allows issuers to ask questions and express concerns – Should include all parties involved with exam

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CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Exam Timeline (cont)

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  • Conduct Exam
  • Create preliminary report

– Provided to entity for review – Provided to state regulators (for informational purposes)

  • Exit Conference

– Discuss findings in preliminary report, including possible CAP – State regulators encouraged to attend

  • Issuer/Plan respond to preliminary report

– Within 30 days of [exit conference or receipt of report?]

  • Final report

– Includes any necessary follow up, CAP and CMPs (if applicable) – State regulators will receive a copy – Issuer may respond (i.e., concur or dispute) to CMS’s positions in the report – CMS will reply to the response form issuer

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CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Post-exam work

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  • Reporting and compliance with CAP
  • Final report posted on website
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CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Questions

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