§18033 Financial integrity

Summary

Require an Exchange to keep clear records of its activities, money received, and money spent, and to send a yearly report to the Secretary. The Secretary, working with the HHS Inspector General, can inspect an Exchange, check its books, ask for regular reports, and must be allowed to investigate. Exchanges must also have yearly audits. If the Secretary finds serious misconduct by an Exchange or a State, the Secretary can hold back up to 1 percent of payments to that State each year until the problems are fixed. The Secretary must run Exchange work efficiently and fairly and can put in place steps to stop fraud and abuse. Any payments through an Exchange that include Federal funds are covered by the False Claims Act (31 U.S.C. 3729 et seq.). Following eligibility rules is required for an issuer to get Exchange payments (including premium tax credits and cost-sharing reductions). If someone is found liable under that Act for such payments, the civil penalty will be increased by not less than 3 times and not more than 6 times the Government’s damages, subject to the provisions of section 3729(a) of title 31. Not later than 5 years after Exchanges must first be running, the Comptroller General must begin an ongoing study of Exchanges and their plans. The study will look at how Exchanges operate, plan performance (including costs, claims, complaints, and whether goals are met), how widely Exchanges are used, recommendations for improvement, the cost and affordability of coverage for small business owners and employees, and whether enough doctors are taking new patients in Federal health programs and whether provider networks are adequate.