The U.S. Department of Health and Human Services (HHS) released proposed rules designed to create a single, streamlined application process for several government health insurance programs. The application process is being developed in preparation for the Health Exchange Programs that begin on January 1, 2014, under the Affordable Care Act.

The proposed rules summarize changes to existing enrollment, eligibility, notice, and appeal provisions of the Medicaid, Children’s Health Insurance Program (CHIP), and similar insurance programs. They also seek to correct various inconsistencies in eligibility and enrollment provisions among the programs.

Published in the Federal Register on January 22, 2013, the regulations are intended to ease the burden on consumers who are eligible for these “insurance affordability programs” and coordinate the appeal process.

The proposed regulations outline the development of:

  • A process for the automatic transfer of financial information from a federal data services hub to an applicable exchange when an individual is determined to be ineligible for Medicaid or other program available for low-income individuals and their families
  • Standardized notices relating to eligibility and enrollment denials
  • A uniform certification procedure for application counselors (to assist individuals in enrolling for the appropriate coverage program)
  • Minimum requirements for the designation of authorized representatives
  • A consolidated appeal process for the adjudication of appeals of individual eligibility for the various programs, as well as employer-sponsored coverage and Small Business Health Insurance Options Program (SHOP) eligibility determinations

In a related development, the Centers for Medicare and Medicaid Services released for comment a draft form of the individual and SHOP application forms on January 28.

As the federal health care reform effort gained steam, Ballard Spahr attorneys established the Health Care Reform Initiative to monitor and analyze legislative developments. With federal health care reform now a reality, our attorneys are assisting health care entities and employers in understanding the relevant changes and planning for the future. They also have launched the Health Care Reform Dashboard, an online resource center for news and analysis on developments under the Affordable Care Act.

If you have questions about the proposed rule or other aspects of the insurance affordability programs, contact Jean C. Hemphill at 215.864.8539 or