PART 600—ADMINISTRATION, ELIGIBILITY, ESSENTIAL HEALTH BENEFITS, PERFORMANCE STANDARDS, SERVICE DELIVERY REQUIREMENTS, PREMIUM AND COST SHARING, ALLOTMENTS, AND RECONCILATION Authority: 42 U.S.C. 300gg, 1395, and 18051. Source: 79 FR 14140, Mar. 12, 2014, unless otherwise noted. Subpart A—General Provisions and Definitions § 600.1 Scope. Section 1331 of the Affordable Care Act, provides for the establishment of the Basic Health Program (BHP) under which a State may enter into contracts for standard health plans providing at least essential health benefits to eligible individuals in lieu of offering such individuals the opportunity to enroll in coverage through an Affordable Insurance Exchange. States that elect to operate a BHP will receive federal funding based on the amount of the premium tax credit and cost-sharing reductions that would have been available if enrollees had obtained coverage through the Exchange. § 600.5 Definitions and use of terms. For purposes of this part, the following definitions apply: Advance payments of the premium tax credit Affordable Care Act Basic Health Program (BHP) Blueprint Certification Code Cost sharing Eligible noncitizen Enrollee Essential health benefits Family and family size Federal fiscal year Federal poverty level or FPL Federal Register Household income Indian Interim certification Lawfully present Minimum essential coverage Modified adjusted gross income Network of health care providers Premium Preventive health services and items Program year Qualified health plan Reference plan Regional compact Residency Single streamlined application Standard health plan Standard health plan offeror State [79 FR 14140, Mar. 12, 2014, as amended at 89 FR 39436, May 8, 2024; 91 FR 29864, May 20, 2026] Subpart B—Establishment and Certification of State Basic Health Programs § 600.100 Program description. A State Basic Health Program (BHP) is operated consistent with a BHP Blueprint that has been certified by the Secretary to meet the requirements of this part. The BHP Blueprint is developed by the State for certification by the Secretary in accordance with the processes described in this subpart. § 600.105 Basis, scope, and applicability of subpart B. (a) Statutory basis. (1) Section 1331(a)(1) which defines a Basic Health Program. (2) Section 1331(a)(2) which requires the Secretary to certify a Basic Health Program before it may become operational. (3) Section 1331(f) which requires Secretarial oversight through annual reviews. (b) Scope and applicability. (2) This subpart applies to all States that submit a BHP Blueprint and request certification to operate a BHP. § 600.110 BHP Blueprint. The BHP Blueprint is a comprehensive written document submitted by the State to the Secretary for certification of a BHP in the form and manner specified by HHS which will include an opportunity for states to submit a limited set of elements necessary for interim certification at the state option. The program must be administered in accordance with all aspects of section 1331 of the Affordable Care Act and other applicable law, this chapter, and the certified BHP Blueprint. (a) Content of a Blueprint. (1) The minimum benefits offered under a standard health plan that assures inclusion of essential health benefits as described in section 1302(b) of the Affordable Care Act, in accordance with § 600.405. (2) The competitive process, consistent with § 600.410, that the State will undertake to contract for the provision of standard health plans. (3) The standard contract requirements, consistent with § 600.415, that the State will incorporate in its standard health plan contracts. (4) The methods by which the State will enhance the availability of standard health plan coverage as described in § 600.420. (5) The methods by which the State will ensure and promote coordination with other insurance affordability programs as described in § 600.425. (6) The premium standards set forth in § 600.505. (7) The cost sharing imposed under the BHP, consistent with the standards described in § 600.510. (8) The disenrollment procedures and consequences for nonpayment of premiums consistent with § 600.525, respectively. (9) The standards, consistent with § 600.305 used to determine eligibility for the program. (10) The State's policies regarding enrollment, disenrollment and verification consistent with §§ 600.320 and 600.345, along with a plan to ensure coordination with and eliminate gaps in coverage for individuals transitioning to other insurance affordability programs. (11) The fiscal policies and accountability procedures, consistent with § 600.710. (12) The process by which BHP trust fund trustees shall be appointed, the qualifications and responsibilities of such trustees, and any arrangements to insure or indemnify such trustees against claims for breaches of their fiduciary responsibilities. (13) A description of how the State will ensure program integrity, including how it will address potential fraud, waste, and abuse and ensure consumer protections. (14) An operational assessment establishing operating agency readiness. (15) A transition plan if a state participating in 2015 plans to propose an alternative enrollment strategy for initial implementation consistent with § 600.145. Such a transition plan must include a plan for coordination of this initial implementation strategy with the Exchange operating in the state, and if beneficiaries will be transitioning from Medicaid, with the Medicaid agency. (b) Funding plan. (2) The funding plan must demonstrate that Federal funds will only be used to reduce premiums and cost-sharing or to provide additional benefits. (c) Transparency. § 600.115 Development and submission of the BHP Blueprint. (a) State authority to submit the State Blueprint. (b) State Basic Health Program officials. (c) Opportunity for public comment. (1) The State must seek public comment on any significant subsequent revisions prior to submission of those revisions to the Secretary for certification. Significant revisions are those that alter core program operations required by § 600.145(f), as well as changes that alter the BHP standard health plan benefit package, or enrollment, disenrollment and verification policies. (2) The process of seeking public comment must include Federally recognized tribes as defined in the Federally Recognized Indian Tribe List Act of 1994, 25 U.S.C. 479a, located in the State. (d) Submission and timing. § 600.120 Certification of a BHP Blueprint. (a) Effective date of certification. (b) Payments for periods prior to certification. (c) Period in which a certified Blueprint remains in effect. (1) The Blueprint is replaced by Secretarial certification of updated Blueprint containing revisions submitted by the State. (2) The State terminates the program consistent with § 600.140. (3) The Secretary makes a finding that the BHP Blueprint no longer meets the standards for certification based on findings in the annual review, or reports significant evidence of beneficiary harm, financial malfeasance, fraud, waste or abuse by the BHP agency or the State consistent with § 600.142. (d) Blueprint approval standards for certification. (1) The Blueprint contains sufficient information for the Secretary to determine that the BHP will comply with the requirements of section 1331 of the Affordable Care Act and this part. (2) The BHP Blueprint demonstrates adequate planning for the integration of BHP with other insurance affordability programs in a manner that will permit a seamless, coordinated experience for a potentially eligible individual. (3) The Blueprint is a complete and comprehensive description of the BHP and its operations, demonstrating thorough planning and a concrete program design, without reserved decisions on operational features. § 600.125 Revisions to a certified BHP Blueprint. (a) Submission of revisions. (1) Changes in Federal law, regulations, policy interpretations, or court decisions that affect provisions in the certified Blueprint; (2) Significant changes that alter core program operations under 600.145(f) or the BHP benefit package; or (3) Changes to enrollment, disenrollment, and verification policies described in the certified Blueprint. (b) Submission and effective dates. (c) Timing of HHS review. (i) Written notice of disapproval; or (ii) Written notice of additional information it needs in order to make a final determination. (2) If HHS requests additional information, the 90-day review period for HHS action on the revised Blueprint— (i) Stops on the day HHS sends a written request for additional information or the next business day if the request is sent on a Federal holiday or weekend; and (ii) Resumes on the next calendar day of the original 90-day review period after HHS receives a complete response from the State including all the requested additional information, unless the information is received after 5 p.m. eastern standard time on a day prior to a non-business day or any time on a non-business day, in which case the review period resumes on the following business day. (3) The 90-day review period cannot stop or end on a non-business day. If the 90th calendar day falls on a non-business day, HHS will consider the 90th day to be the next business day. (4) HHS may send written notice of its need for additional information as many times as necessary to obtain the complete information necessary to review the revised Blueprint. (5) HHS may disapprove a Blueprint that is not consistent with section 1331 of the ACA or the regulations set forth in this Part at any time during the review process, including when the 90-day review clock is stopped due to a request for additional information. (d) Continued operation. (1) The State adopts a revised Blueprint by obtaining approval by HHS under this section; (2) The State follows the procedures described in § 600.140(a) for terminating a BHP; (3) The State follows the procedures described in § 600.140(b) for suspending a BHP; (4) The Secretary withdraws certification of a BHP under 600.142. (e) Withdrawal of a revised Blueprint. (f) Reconsideration of decision. (g) Public health emergency. [88 FR 79553, Nov. 16, 2023] § 600.130 Withdrawal of a BHP Blueprint prior to implementation. To the extent that a State has not enrolled eligible individuals into the BHP: (a) The State may submit a written request to stop any further consideration of a previously submitted BHP Blueprint, whether certified or not. (b) The written request must be signed by the governor, or the State official delegated to sign the BHP Blueprint by the governor. (c) HHS will respond with a written confirmation that the State has withdrawn the Blueprint. § 600.135 Notice and timing of HHS action on an initial BHP Blueprint submission. (a) Timely response. (b) Issues preventing certification. (c) Reconsideration of decision. [79 FR 14140, Mar. 12, 2014, as amended at 88 FR 79554, Nov. 16, 2023] § 600.140 State termination of a BHP. A State that no longer wishes to operate a BHP may terminate or suspend its BHP. (a) If a State decides to terminate its BHP, the State must complete all of the following prior to the effective date of the termination or the indicated dates: (1) Submit written notice to the Secretary no later than 120 days prior to the proposed termination date accompanied by a proposed transition plan that describes procedures to assist consumers with transitioning to other insurance affordability programs. (2) Resolve concerns expressed by the Secretary and obtain approval by the Secretary of the transition plan. (3) Submit written notice to all participating standard health plan offerors, and enrollees that it intends to terminate the program at least 90 days prior to the termination date. The notices to enrollees must include information regarding the State's assessment of their eligibility for all other insurance affordability programs in the State. Notices must meet the accessibility and readability standards at 45 CFR 155.230(b). (4) Transmit all information provided as part of an application, and any information obtained or verified by the State or other agencies administering insurance affordability programs via secure electronic interface, promptly and without undue delay to the agency administering the Exchange and the Medicaid agency as appropriate. (5) Fulfill its contractual obligations to participating standard health plan offerors including the payment of all negotiated rates for participants, as well as plan oversight ensuring that participating standard health plan offerors fulfill their obligation to cover benefits for each enrollee. (6) Fulfill data reporting requirements to HHS. (7) Complete the annual financial reconciliation process with HHS to ensure full compliance with Federal financial obligations. (8) Refund any remaining balance in the BHP trust fund. (b) If a State decides to suspend its BHP, or to request an extension of a previously-approved suspension, the State must: (1) Submit to the Secretary a suspension application or a suspension extension application, as applicable. The suspension or suspension extension application must: (i) Demonstrate that the benefits BHP-eligible individuals will receive during the suspension are at least equal to the benefits provided under the certified BHP Blueprint in effect on the effective date of suspension; (ii) Demonstrate that the median actuarial value of the coverage provided to the BHP-eligible individuals during the suspension is no less than the median actuarial value of the coverage under the certified BHP Blueprint in effect on the effective date of suspension; (iii) Demonstrate that the premiums imposed on BHP-eligible individuals during the suspension are no higher than the premiums charged under the certified BHP Blueprint in effect on the effective date of suspension, except that premiums imposed during the suspension may be adjusted for inflation, as measured by the Consumer Price Index; (iv) Demonstrate that the eligibility criteria for coverage during the suspension is not more restrictive than the criteria described in § 600.305; (v) Describe the period, not to exceed 5 years, that the State intends to suspend its BHP or to extend a previously-approved suspension; (vi) Be submitted at least 9 months in advance of the proposed effective date of the suspension or extension, except States seeking to suspend a BHP in 2024 must submit an application within 30 days of the effective date of this provision; and (vii) Include an evaluation of the coverage provided to BHP eligible individuals during the suspension period, if the State is seeking an extension. (2) Resolve concerns expressed by HHS and obtain approval by the Secretary of the suspension or suspension extension application. Suspensions may not be in effect prior to approval by HHS, except for States seeking to suspend a BHP in 2024. (3) At least 90 days prior to the effective date of the suspension, provide written notice to all enrollees and participating standard health plan offerors that it intends to suspend the program, if the enrollees will experience a change in coverage, or standard health plan offerors will experience a change in the terms of coverage. The notices to enrollees must include information regarding the State's assessment of their eligibility for all other insurance affordability programs in the State. Notices must meet the accessibility and readability standards at 45 CFR 155.230(b). (4) Within 12 months of the suspension effective date, submit to HHS the data required by § 600.610 to complete the financial reconciliation process with HHS. (5) Submit the annual report required by § 600.170(a)(2), describing the balance of the trust fund, and any interest accrued on such amount. (6) Annually, remit to HHS any interest that has accrued on the balance of the BHP trust fund during the suspension period in the form and manner specified by HHS. (7) At least 9 months before the end of the suspension period described in paragraph (b)(1)(iv) of this section, or earlier date elected by the State, the State must submit to HHS a transition plan that describes how the State will reinstate its BHP consistent with the requirements of this part, or terminate the program in accordance with paragraph (a) of this section. The State must meet the noticing requirements of paragraph (b)(3) of this section prior to terminating or reinstating the BHP. (c) The Secretary may withdraw approval of the suspension plan, if the terms of paragraph (b) of this section are not met, if the State ends implementation of the alternative coverage program for any reason, or if HHS finds significant evidence of beneficiary harm, financial malfeasance, fraud, waste, or abuse by the BHP agency or the State consistent with § 600.142 of this part. If HHS withdraws the approved suspension plan, the State must reinstate its BHP under the terms of this part, or terminate the program under paragraph (a) of this section. (1) The Secretary may withdraw approval of a suspension under this section only after the Secretary provides the State with notice of the findings upon which the Secretary is basing the withdrawal; a reasonable period for the State to address the finding; and an opportunity for a hearing before issuing a final finding. (2) The Secretary must make every reasonable effort to work with the State to resolve proposed findings without withdrawing approval of a suspension and in the event of a decision to withdraw approval, will accept a request from the State for reconsideration. (3) The effective date of an HHS determination withdrawing approval of the suspension plan shall not be earlier than 120 days following issuance of a final finding under paragraph (d)(1) of this section. (4) Within 30 days following a final finding under paragraph (d)(1) of this section, the State must submit a transition plan to HHS. [79 FR 14140, Mar. 12, 2014, as amended at 88 FR 79554, Nov. 16, 2023] § 600.142 HHS withdrawal of certification and termination of a BHP. (a) The Secretary may withdraw certification for a BHP Blueprint based on a finding that the BHP Blueprint no longer meets the standards for certification based on findings in the annual review, findings from a program review conducted in accordance with § 600.200 or from significant evidence of beneficiary harm, financial malfeasance, fraud, waste or abuse. (b) Withdrawal of certification for a BHP Blueprint shall occur only after the Secretary provides the State with notice of the proposed finding that the standards for certification are not met or evidence of harm or misconduct in program operations, a reasonable period for the State to address the finding (either by substantiating compliance with the standards for certification or submitting revisions to the Blueprint, or securing HHS approval of a corrective action plan), and an opportunity for a hearing before issuing a final finding. (c) The Secretary shall make every reasonable effort to resolve proposed findings without requiring withdrawal of BHP certification and in the event of a decision to withdraw certification, will accept a request from the State for reconsideration. (d) The effective date of an HHS determination withdrawing BHP certification shall not be earlier than 120 days following a final finding of noncompliance with the standards for certification. (e) Within 30 days following a final finding of noncompliance with the standards for certification, the State shall submit a transition plan that describes procedures to assist consumers with transitioning to other insurance affordability programs, and shall comply with the procedures described in § 600.140(a)(2) through (8). § 600.145 State program administration and operation. (a) Program operation. (1) The approved and fully certified State BHP Blueprint, any approved modifications to the State BHP Blueprint and the requirements of this chapter and applicable law; or (2) The approved suspension application described in § 600.140. (b) Eligibility. (c) Statewide program operation. (d) No caps on program enrollment. (e) Transition plan. (f) Core operations. (1) Eligibility determinations as specified in § 600.320. (2) Eligibility and health services appeals as specified in 600.335. (3) Contracting with standard health plan offerors as specified in § 600.410. (4) Oversight and financial integrity including, but not limited to, operation of the Trust Fund specified at §§ 600.705 and 600.710, compliance with annual reporting at § 600.170, and providing data required by § 600.610 for Federal funding and reconciliation processes. (5) Consumer assistance as required in § 600.150. (6) Extending protections to American Indian/Alaska Natives specified at § 600.160, as well as comply with the Civil Rights and nondiscrimination provisions specified at § 600.165. (7) Data collection and reporting as necessary for efficient and effective operation of the program and as specified by HHS to support program oversight. (8) If necessary, program termination procedures at § 600.145. [79 FR 14140, Mar. 12, 2014, as amended at 88 FR 79555, Nov. 16, 2023] § 600.150 Enrollment assistance and information requirements. (a) Information disclosure. (2) The State must provide accessible information on coverage, including additional benefits that may be provided outside of the standard health plan coverage, any tiers of coverage it has built into the BHP, including who is eligible for each tier. (3) The State must require participating standard health plans to provide clear information on premiums; covered services including any limits on amount, duration and scope of those services; applicable cost-sharing using a standard format supplied by the State, and other data specified in, and in accordance with, 45 CFR 156.220. (4) The State must provide information in a manner consistent with 45 CFR 155.205(c). (5) The State must require participating standard health plans to make publicly available, and keep up to date (at least quarterly), the names and locations of currently participating providers. (b) [Reserved] § 600.155 Tribal consultation. The State must consult with Indian tribes located in the State on the development and execution of the BHP Blueprint using the tribal consultation policy approved by the State Exchange. § 600.160 Protections for American Indian and Alaska Natives. (a) Enrollment. (b) Cost sharing. (c) Payments to providers. (d) Requirement. § 600.165 Nondiscrimination standards. (a) The State and standard health plans, must comply with all applicable civil rights statutes and requirements, including Title VI of the Civil Rights Act of 1964, Title II of the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Section 1557 of the Affordable Care Act, and 45 CFR part 80, part 84, and part 91 and 28 CFR part 35. (b) The State must comply with the nondiscrimination provision at 45 CFR 155.120(c)(2). § 600.170 Annual report content and timing. (a) Content. (i) Eligibility verification requirements for program participation as specified in § 600.345. (ii) Limitations on the use of Federal funds received by the BHP as specified in § 600.705. (iii) Requirements to collect quality and performance measures from all participating standard health plans focusing on quality of care and improved health outcomes as specified in sections 1311(c)(3) and (4) of the Affordable Care Act and as further described in § 600.415. (iv) Requirements specified by the Secretary at least 120 days prior to the date of the annual report as requiring further study to assess continued State compliance with Federal law, regulations and the terms of the State's certified Blueprint, based on a Federal review of the BHP pursuant to § 600.200, and/or a list of any outstanding recommendations from any audit or evaluation conducted by the HHS Office of Inspector General that have not been fully implemented, including a statement describing the status of implementation and why implementation is not complete. (2) A State that has suspended its BHP under § 600.140(b) of this part must submit an annual report that includes the following: (i) The balance of the BHP trust fund and any interest accrued on that balance; (ii) An assurance that the coverage provided to individuals who would be eligible for a BHP under § 600.305 of this part continues to meet the standards described in § 600.140(b)(1)(i), (ii), and (iii) of this part; and (iii) Any additional information specified by the Secretary at least 120 days prior to the date of the annual report. (b) Timing. [79 FR 14140, Mar. 12, 2014, as amended at 88 FR 79555, Nov. 16, 2023] Subpart C—Federal Program Administration § 600.200 Federal program compliance reviews and audits. (a) Federal compliance review of the State BHP. (b) Action on compliance review findings. (1) Requirements that need further study or data to assess continued State compliance with Federal law, regulations and the terms of the State's certified Blueprint. Such findings must be addressed in the next State annual report due no more than 120 days after the date of the issuance of the Federal compliance review. (2) Requirements with which the State BHP does not appear to be in compliance that could be the basis for withdrawal of BHP certification. Such findings must be resolved by the State (either by substantiating compliance with the standards for certification or submitting revisions to the Blueprint). If not resolved, such action items can be the basis for a proposed finding for withdrawal of BHP certification. (3) Requirements with which the State BHP does not appear to be in compliance and are not a basis for withdrawal of BHP certification but require revision to the Blueprint must be resolved by the State. If not resolved, such action items can be the basis for denial of other Blueprint revisions. (4) Improper use of BHP trust fund resources. (c) The HHS Office of Inspector General (OIG) may periodically audit State operations and standard health plan practices as described in § 430.33 of this chapter. Final reports on those audits shall be transmitted to both the State and the Secretary for actions on findings. The State and the BHP trustees shall be given an opportunity to resolve concerns about improper use of BHP trust funds as indicated in § 600.715(a) through (c): either by substantiating the proper use of trust fund, or by taking corrective action that includes changes to procedures to ensure proper use of trust fund resources, and restitution of improperly used resources to the trust fund. Subpart D—Eligibility and Enrollment § 600.300 Basis, scope, and applicability. (a) Statutory basis. (b) Scope and applicability. § 600.305 Eligible individuals. (a) Eligibility standards (1) Are residents of the State. (2) Have household income which exceeds 133 percent but does not exceed 200 percent of the FPL for the applicable family size, or, in the case of an individual who is a lawfully present non-citizen, ineligible for Medicaid or CHIP due to such immigration status, whose household income is between zero and 200 percent of the FPL for the applicable family size. (3) Are not eligible to enroll in minimum essential coverage (other than a standard health plan). If an individual meets all other eligibility standards, and— (i) Is eligible for, or enrolled in, coverage that does not meet the definition of minimum essential coverage, including Medicaid that is not minimum essential coverage, the individual is eligible to enroll in a standard health plan without regard to eligibility or enrollment in Medicaid; or (ii) Is eligible for Employer Sponsored Insurance (ESI) that is unaffordable (as determined under section 36B(c)(2)(C) of the Internal Revenue Code), the individual is eligible to enroll in a standard health plan. (4) Are 64 years of age or younger. (5) Are either a citizen or lawfully present non-citizen. (6) Are not incarcerated, other than during a period pending disposition of charges. (b) Eligibility restrictions. § 600.310 Application. (a) Single streamlined application. (b) Opportunity to apply and assistance with application. (c) Authorized representatives. § 600.315 Certified application counselors. The State may have a program to certify application counselors to assist individuals to apply for enrollment in the BHP and other insurance affordability programs. If the State chooses this option, the State must follow the procedures and standards for such a program set forth in the regulations at either 45 CFR 155.225 or 42 CFR 435.908. § 600.320 Determination of eligibility for and enrollment in a standard health plan. (a) Determining eligibility to enroll in a standard health plan may be performed by a State or through delegation to a local governmental entity, including a governmental entity that determines eligibility for Medicaid or CHIP, and may be delegated by the State to an Exchange that is a government agency. (b) Timely determinations. (c) Effective date of eligibility. (1) Follows the Exchange effective date standards at 45 CFR 155.420(b)(1); (2) Follows the Medicaid effective date standards at § 435.915 of this chapter exclusive of § 435.915(a);or (3) Follows an effective date of eligibility of the first day of the month following the month in which BHP eligibility is determined; or (4) Follows an effective date of eligibility standard established by the State and subject to HHS approval to ensure that the effective date is: (i) No later than the first day of the second month following the date that an individual has been determined BHP-eligible; and (ii) No more restrictive than paragraphs (c)(1) through (3) of this section. (d) Enrollment periods. [79 FR 14140, Mar. 12, 2014, as amended at 89 FR 26419, Apr. 15, 2024; 91 FR 33482, June 3, 2026] § 600.330 Coordination with other insurance affordability programs. (a) Coordination. (b) Coordinated determinations of eligibility. (c) Account transfers. (d) Notification to referring agency. (e) Notice of decision concerning eligibility. (f) Accessibility. [79 FR 14140, Mar. 12, 2014, as amended at 88 FR 79555, Nov. 16, 2023; 89 FR 22878, Apr. 2, 2024] § 600.335 Appeals. (a) Notice of eligibility appeal rights. (b) Appeals process. (1) BHP eligibility determinations; and (2) Delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of service, after individuals exhaust appeals or grievances through the BHP standard health plans. (c) Exception. (1) The State has oversight of any entity delegated the authority to administer appeals; (2) The agency to which eligibility determinations or appeals decisions are delegated complies with all relevant Federal and State law, regulations and policies; and (3) The agency to which eligibility determinations or appeals decisions are delegated informs applicants and beneficiaries how they can directly contact and obtain information from the agency. (d) Accessibility. [79 FR 14140, Mar. 12, 2014, as amended at 88 FR 79555, Nov. 16, 2023] § 600.340 Periodic redetermination and renewal of BHP eligibility. (a) Periodic review of eligibility. (b) Renewal of coverage. (c) Procedures. (d) Verification. (e) Notice to enrollee. (f) Continuous eligibility. § 600.345 Eligibility verification. (a) The State must verify the eligibility of an applicant or beneficiary for BHP consistent either with the standards and procedures set forth in— (1) Medicaid regulations at §§ 435.945 through 435.956 of this chapter; or (2) Exchange regulations at 45 CFR 155.315 and 155.320. (b) [Reserved] § 600.350 Privacy and security of information. The State must comply with the standards and procedures set forth in 45 CFR 155.260(b) and (c) as are applicable to the operation of the BHP. Subpart E—Standard Health Plan § 600.400 Basis, scope, and applicability. (a) Statutory basis. (b) Scope and applicability. § 600.405 Standard health plan coverage. (a) Essential Health Benefits (EHB). (b) Additional required benefits. (c) Periodic review. (d) Non-discrimination in benefit design. (e) Compliance. § 600.410 Competitive contracting process. (a) General requirement. (b) Contracting process. (1) Conduct the contracting process in a manner providing full and open competition consistent with the standards of 45 CFR 92.36(b) through (i); (2) Include a negotiation of the elements described in paragraph (d) of this section on a fair and adequate basis; and (3) Consider the additional elements described in paragraph (e) of this section. (c) Initial implementation exceptions. (2) The State must include a proposed timeline that implements a competitive contracting process, as described in paragraph (b) of this section, for program year 2016. (3) Initial implementation exceptions are subject to HHS approval consistent with the BHP Blueprint review process established in § 600.120, and may only be in effect for benefit year 2015. (d) Negotiation criteria. (1) Premiums and cost sharing, consistent with the requirements at §§ 600.505 and 600.510(e); (2) Benefits, consistent with the requirements at § 600.405; (3) Inclusion of innovative features, such as: (i) Care coordination and care management for enrollees, with a particular focus on enrollees with chronic health conditions; (ii) Incentives for the use of preventive services; and (iii) Establishment of provider-patient relationships that maximize patient involvement in their health care decision-making, including the use of incentives for appropriate health care utilization and patient choice of provider. (e) Other considerations: (1) Consideration of health care needs of enrollees; (2) Local availability of, and access, to health care providers to ensure the appropriate number, mix and geographic distribution to meet the needs of the anticipated number of enrollees in the service area (including but not limited to services provided by essential community providers, as defined in 45 CFR 156.235) so that access to services is at least sufficient to meet the access standards applicable under 42 CFR part 438, subpart D, or 45 CFR 156.230 and 156.235; (3) Use of a managed care process, or a similar process to improve the quality, accessibility, appropriate utilization, and efficiency of services provided to enrollees; (4) Performance measures and standards focused on quality of care and improved health outcomes as specified in § 600.415; (5) Coordination between other health insurance affordability programs to ensure enrollee continuity of care as described in § 600.425; and (6) Measures to prevent, identify, and address fraud, waste and abuse and ensure consumer protections. (f) Discrimination. § 600.415 Contracting qualifications and requirements. (a) Eligible offerors for standard health plan contracts. (1) Licensed health maintenance organization. (2) Licensed health insurance insurer. (3) Network of health care providers demonstrating capacity to meet the criteria set forth in § 600.410(d). (4) Non-licensed health maintenance organizations participating in Medicaid and/or CHIP. (b) General contract requirements. (2) All contracts under this part must include provisions that define a sound and complete procurement contract, as required by 45 CFR 92.36(i). (3) To the extent that the standard health plan is health insurance coverage offered by a health insurance issuer, the contract must provide that the medical loss ratio is at least 85 percent. (c) Notification of State election. § 600.420 Enhanced availability of standard health plans. (a) Choice of standard health plans offerors. (2) If a State is not able to assure choice of standard health plan offerors, the State may request an exception to the requirement set forth in paragraph (a)(1) of this section, which must include a justification as to why it cannot assure choice of standard health plan offeror as well as demonstrate that the State has reviewed its competitive contracting process to determine the following: (i) Whether all contract requirements and qualifications are required under the federal framework for BHP; (ii) Whether additional negotiating flexibility would be consistent with the minimum statutory requirements and available BHP funding: and (iii) Whether potential bidders have received sufficient information to encourage participation in the BHP competitive contracting process. (b) Use of regional compacts. (2) A State electing the option described in paragraph (b)(1) of this section that also contracts for the provision of a geographically specific standard health plan must assure that enrollees, regardless of residency within the State, continue to have choice of at least two standard health plans. (3) A State electing the option described in paragraph (b)(1) of this section must include in its BHP Blueprint all of the following: (i) The other State(s) entering into the regional compact. (ii) The specific areas within the participating States that the standard health plans will operate, if applicable. (A) If the State contracts for the provision of a geographically specific standard health plan, the State must describe in its BHP Blueprint how it will assure that enrollees, regardless of location within the State, continue to have choice of at least two standard health plan offerors. (B) [Reserved] (iii) An assurance that the competitive contracting process used in the joint procurement of the standard health plans complies with the requirements set forth in § 600.410. (iv) Any variations that may occur as a result of regional differences between the participating states with respect to benefit packages, premiums and cost sharing, contracting requirements and other applicable elements as determined by HHS. § 600.425 Coordination with other insurance affordability programs. A State must ensure coordination for the provision of health care services to promote enrollee continuity of care between Medicaid, CHIP, Exchange and any other state-administered health insurance programs. The State's BHP Blueprint must describe how it will ensure such coordination. Subpart F—Enrollee Financial Responsibilities § 600.500 Basis, scope, and applicability. (a) Statutory basis. (b) Scope and applicability. § 600.505 Premiums. (a) Premium requirements. (2) This assurance must be reflected in the BHP Blueprint, which shall also include: (i) The group or groups of enrollees subject to premiums. (ii) The collection method and procedure for the payment of an enrollee's premium. (iii) The consequences for an enrollee or applicant who does not pay a premium. (b) [Reserved] § 600.510 Cost-sharing. (a) Cost-sharing requirements. (i) The cost sharing imposed on enrollees meet the standards detailed in § 600.520(c). (ii) The establishment of an effective system to monitor and track the cost-sharing standards consistent with § 600.520(b) through (d). (2) This assurance must be reflected in the BHP Blueprint, which shall also include the group or groups of enrollees subject to the cost sharing. (b) Cost sharing for preventive health services. § 600.515 Public schedule of enrollee premium and cost sharing. (a) The State must ensure that applicants and enrollees have access to information about all of the following, either upon request or through an Internet Web site: (1) The amount of and types of enrollee premiums and cost sharing for each standard health plan that would apply for individuals at different income levels. (2) The consequences for an applicant or an enrollee who does not pay a premium. (b) The information described in paragraph (a) of this section must be made available to applicants for standard health plan coverage and enrollees in such coverage, at the time of enrollment and reenrollment, after a redetermination of eligibility, when premiums, cost sharing, and annual limitations on cost sharing are revised, and upon request by the individual. § 600.520 General cost-sharing protections. (a) Cost-sharing protections for lower income enrollees. (b) Cost-sharing protections to ensure enrollment of Indians. (c) Cost-sharing standards. (1) The standards in accordance with 45 CFR 156.420(c) and (e); and (2) The cost-sharing reduction standards in accordance with 45 CFR 156.420(a)(1) for an enrollee with household income at or below 150 percent of the FPL, and 45 CFR 156.420(a)(2) for an enrollee with household income above 150 percent of the FPL. (3) The State must establish an effective system to monitor compliance with the cost-sharing reduction standards in paragraph (c) of this section, and the cost-sharing protections to ensure enrollment of Indians in paragraph (b) of this section to ensure that enrollees are not held responsible for such monitoring activity. (d) Acceptance of certain third party payments. (1) Ryan White HIV/AIDS Programs under title XXVI of the Public Health Service Act; (2) Indian tribes, tribal organizations or urban Indian organizations; and (3) State and federal government programs. § 600.525 Disenrollment procedures and consequences for nonpayment of premiums. (a) Disenrollment procedures due to nonpayment of premium. (2) A State electing to enroll eligible individuals in accordance with 45 CFR 155.410 and 155.420 must comply with the premium grace period standards set forth in 45 CFR 156.270 for required premium payment prior to disenrollment. (3) A State electing to enroll eligible individuals throughout the year must provide an enrollee a 30-day grace period to pay any required premium prior to disenrollment. (b) Consequences of nonpayment of premium. (2) A State electing to enroll eligible individuals throughout the year must comply with the reenrollment standards set forth in § 457.570(c) of this chapter. [79 FR 14140, Mar. 12, 2014, as amended at 89 FR 22878, Apr. 2, 2024] Subpart G—Payment to States § 600.600 Basis, scope, and applicability. (a) Statutory basis. (b) Scope and applicability. § 600.605 BHP payment methodology. (a) General calculation. (1) Premium tax credit component. (2) Cost-sharing reduction component. (b) Relevant factors in the payment methodology. (1) Age of the enrollee; (2) Income of the enrollee; (3) Self-only or family coverage; (4) Geographic differences in average spending for health care across rating areas; (5) Health status of the enrollee for purposes of determining risk adjustment payments and reinsurance payments had the enrollee been enrolled in a qualified health plan through an Exchange; (6) Reconciliation of the premium tax credit or cost-sharing reductions had such reconciliation occurred if an enrollee had been enrolled in a qualified health plan through an Exchange; (7) Marketplace experience in other states with respect to Exchange participation and the effect of the premium tax credit and cost-sharing reductions provided to residents, particularly those residents with income below 200 percent of the FPL; and (8) Other factors affecting the development of the methodology as determined by the Secretary. (c) Annual adjustments to payment methodology. § 600.610 Secretarial determination of BHP payment amount. (a) Proposed payment notice. Federal Register (i) In years in which the Secretary does not publish a new BHP methodology, the Secretary will update the values of factors needed to calculate the Federal BHP payments via sub regulatory guidance, as appropriate. (ii) In years that the Secretary publishes a revised payment methodology, the Secretary will publish a proposed BHP payment methodology upon receiving certification from the Chief Actuary of CMS. (2) A State may be required to submit data in accordance with the published proposed payment document in order for the Secretary to determine the State's payment rate as described in paragraph (b) of this section. (b) Final payment notice. Federal Register (2) Calculation of payment rates. (c) State specific aggregate BHP payment amounts Prospective aggregate payment amount. (2) Retrospective adjustment to state specific aggregate payment amount for enrollment and errors. (ii) Upon determination that a mathematical error occurred during the application or development of the BHP funding methodology, the Secretary will recalculate the state's BHP payment amount and make any necessary adjustments in accordance with paragraph (c)(2)(iv) of this section. (iii) To the extent that the final payment notice described in paragraph (b) of this section permits retrospective adjustments to the state's BHP payment amount (due to the lack of necessary data for the Secretary to prospectively determine the relevant factors comprising the premium tax credit and cost-sharing reductions components of the BHP funding methodology), the Secretary will recalculate the state's BHP payment amount and make any necessary adjustments in accordance with paragraph (c)(2)(iv) of this section. (iv) Any difference in the adjusted payment and the prospective aggregate payment amount will result in either: (A) A deposit of the difference amount into the State's BHP trust fund; or (B) A reduction in the upcoming quarter's prospective aggregate payment as described in paragraph (c)(1) of this section by the difference amount. [79 FR 14140, Mar. 12, 2014, as amended at 87 FR 77742, Dec. 20, 2022] § 600.615 Deposit of Federal BHP payment. HHS will make quarterly deposits into the state's BHP trust fund based on the aggregate quarterly payment amounts described in § 600.610(c). Subpart H—BHP Trust Fund § 600.700 Basis, scope, and applicability. (a) Statutory basis. (b) Scope and applicability. § 600.705 BHP trust fund. (a) Establishment of BHP trust fund. (2) The State must identify trustees responsible for oversight of the BHP trust fund. (3) Trustees must specify individuals with the power to authorize withdrawal of funds for allowable trust fund expenditures. (b) Non-Federal deposits. (c) Allowable trust fund expenditures. (1) Reduce premiums and cost sharing for eligible individuals enrolled in standard health plans under BHP; or (2) Provide additional benefits for eligible individuals enrolled in standard health plans as determined by the State. (d) Limitations. (1) Determining the amount of non-Federal funds for the purposes of meeting matching or expenditure requirements for Federal funding; (2) Program administration of BHP or any other program; (3) Payment to providers not associated with BHP services or requirements; or (4) Coverage for individuals not eligible for BHP. (e) Year-to-year carryover of trust funds. § 600.710 Fiscal policies and accountability. The BHP administering agency must assure the fiscal policies and accountability set forth in paragraphs (a) through (g) of this section. This assurance must be reflected in the BHP Blueprint. (a) Accounting records. (b) Annual certification. (1) The State's BHP trust fund financial statements for the fiscal year. (2) The BHP trust funds are not being used as the non-Federal share for purposes of meeting any matching or expenditure requirement of any Federally-funded program. (3) The use of BHP trust funds is in accordance with Federal requirements consistent with those specified for the administration and provision of the program. (c) Independent audit. (d) Annual reports. (e) Restitution. (f) Record retention. (g) Record retention related to audit findings. § 600.715 Corrective action, restitution, and disallowance of questioned BHP transactions. (a) Corrective action. (b) Restitution. (c) Timing of restitution. (d) HHS disallowance of improper BHP trust fund expenditures. (1) The date or dates of the improper expenditures from the BHP trust fund; (2) A brief written explanation of the basis for the determination that the expenditures were improper; and (3) Procedures for administrative reconsideration of the disallowance based on a final determination. (e) Administrative reconsideration of BHP trust fund disallowances. (2) After receipt of a reconsideration request, if the Secretary (or a designated hearing officer) determines that further proceedings would be warranted, the Secretary may issue a request for further information by a specific date, or may schedule a hearing to obtain further evidence or argument. (3) The Secretary, or designee, shall issue a final decision within 90 days after the later of the date of receipt of the reconsideration request or date of the last scheduled proceeding or submission. (f) Return of disallowed BHP funding.